position would be most appropriate? ■ 1. The head of the bed elevated 30 to 45 degrees. ■ 2. Trendelenburg’s position. ■ 3. Left Sims position. ■ 4. The head elevated on two pillows. 12. The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? ■ 1. Muscle relaxation. ■ 2. Intake and output. ■ 3. Widening of the pulse pressure. ■ 4. Pupil dilation. 13. A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client’s arrival? Select all that apply. ■ 1. Refl exes. ■ 2. Bladder function. ■ 3. Blood pressure. ■ 4. Temperature. ■ 5. Respirations. 14. The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? ■ 1. The client’s shoulders shrug against downward pressure of the examiner’s hands. ■ 2. The client’s arm pulls up from a resting position against resistance. ■ 3. The client’s arm straightens out from a fl exed position against resistance. ■ 4. The client’s hand-grasp strength is equal. 15. Four days after surgery for internal fi xation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. ■ 1. Back at the level of the client’s scapula. ■ 2. Back and head that are high. ■ 3. Seat that is lower than normal. ■ 4. Seat with fi rm cushions. ■ 5. Chair controlled by the client’s breath. 16. A male client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? ■ 1. “I’ll get your family.” ■ 2. “Can you tell me your name and where you live?” ■ 3. “I’ll bet you’re a little confused right now.” ■ 4. “You are in the hospital. You were in an accident
with attempts to: ■ 1. Tolerate the pain. ■ 2. Decrease the perception of pain. ■ 3. Escape the source of pain. ■ 4. Divert attention from the source of pain. 105. Ergotamine tartrate (Gynergen) is prescribed for a client’s migraine headaches. The client’s report of which of the following indicates effectiveness? ■ 1. Prevention of the migraine. ■ 2. Reduced severity of the developing migraine. ■ 3. Relief from the sleeplessness experienced in the past after a migraine. ■ 4. Relief from the vision problems experienced in the past after a migraine. 106. The nurse explains to the client with pain that the purpose of biofeedback is to enable him to exert control over his physiologic processes by: ■ 1. Regulating the body processes through electrical control. ■ 2. Shocking himself when an undesirable response is elicited. ■ 3. Monitoring the body processes for the therapist to interpret. ■ 4. Translating the signals of his body processes into observable forms. 107. The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage: ■ 1. Blocks pain impulses from the spinal cord to the brain. ■ 2. Blocks pain impulses from the brain to the spinal cord. ■ 3. Stimulates the release of endorphins. ■ 4. Distracts the client’s focus on the source of the pain. 108. Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include: ■ 1. Reassuring the client that pain will be relieved. ■ 2. Documenting the client’s response to pain medication on a routine basis. ■ 3. Instructing the client to continue pressing the system’s button whenever pain occurs. ■ 4. Titrating the client’s pain medication until the client is free from pain. 109. A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do fi rst? ■ 1. Check the patient-controlled analgesia (PCA) pump function.