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ATI LPN Med Surg Exam 4
Total Questions : 54
Showing 10 questions, Sign in for moreA nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?
A nurse is collecting data on a client who has multiple sclerosis. The client reports there are times when the symptoms are active and times when there are no symptoms. Which of the following types of multiple sclerosis does this pattern indicate?
Day 1:
Oriented to person, place, and time. Speech is slow. Unilateral resting tremors noted in right arm. Gait is slow and rigid.
6 months later:
Oriented to person and place, disoriented to date and time. Speech is slow and slurred. Bilateral resting tremors noted in extremities and generalized muscle stiffness. Facial rigidity and drooling noted. Gait is slow and client shuffles their feet when ambulating.
A nurse is caring for a client.
For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.
Explanation
Assessment Findings and Rationale
1. Ambulation Pattern
Parkinson's Disease: The slow and shuffling gait is characteristic of Parkinson's disease due to muscle rigidity and bradykinesia (slowness of movement). Patients often exhibit a stooped posture and a shuffling gait.
2. Muscle Movements
Parkinson's Disease: Unilateral resting tremors and generalized muscle stiffness are hallmark signs of Parkinson's disease, which affects motor control due to basal ganglia degeneration. As the disease progresses, bilateral tremors and stiffness develop.
3. Speech
Parkinson's Disease: Slow and slurred speech is common in Parkinson's disease as a result of muscle rigidity affecting speech production.
Stroke: Speech difficulties such as slurred speech may also occur in stroke patients due to dysarthria, which arises from motor control deficits.
Multiple Sclerosis: Speech issues, including slurred speech, can also be seen in multiple sclerosis due to neurological involvement and muscle control issues.
4. Orientation Status
Parkinson's Disease: Disorientation to date and time can be seen in later stages of Parkinson's disease as cognitive decline may accompany the motor symptoms.
Stroke: Cognitive deficits, including disorientation, can result from stroke, especially if it affects the areas of the brain responsible for cognition.
Multiple Sclerosis: Orientation issues may also occur in multiple sclerosis as cognitive impairment can be part of the disease process.
5. Facial Rigidity
Parkinson's Disease: Facial rigidity, often described as a "masked face," is a classic symptom of Parkinson's disease, resulting from decreased facial muscle control.
A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension?
A nurse is assisting with the admission of a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse anticipate the provider prescribing to decrease ICP?
A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply)
A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea, and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?
A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?
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