MSN 377 EXAM 4

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? A. I will perform self-catherterization at least six times per day B. a reflex erection may cause an unsafe drop in blood pressure C. if I develop a severe headache, I will lie down for 15 to 20 minutes D. I can avoid this problem by taking medications to prevent leg spasms

A. I will perform self-catherterization at least six times per day Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion

A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? A. position the patient on her weak side the majority of the time B. alternating the patient's positioning between supine and side-lying C. avoid the use of pillows in order to promote independence in positioning D. establish a schedule for the massage of areas where skin breakdown occurs

B. alternating the patient's positioning between supine and side-lying

A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. test the drainage for the presence of glucose B. apply a loose gauze pad under the patient's nose C. place the patient in a modified trendelenburg position D. ask the patient to gently blow the nose to clear the drainage

B. apply a loose gauze pad under the patient's nose Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present.

A nurse in an ED is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is having a myasthenic crisis, which of the following actions is the nurse's priority? A. administer artificial tears B. assist with a tensilon test C. administer immunosuppressants D. assist with plasmapheresis

B. assist with a tensilon test The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine whether the client is having a myasthenic crisis or a cholinergic crisis.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. tachypnea B. bradycardia C. hypotension D. narrowing pulse pressure

B. bradycardia

which assessment data for a patient who has Guillain-Barre syndrome will require the nurses most immediate action? A. the patients sacral area skin is reddened B. the patient is continuously drooling saliva C. the patient complains of severe pain in the feet D. the patients blood pressure is 150/82

B. the patient is continuously drooling saliva

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A. administer IV mannitol B. ventilator use to hyperoxygenate the patient C. use strict aseptic technique with dressing changes D. be aware of changes in ICP related to leaking cerebrospinal fluid

C. use strict aseptic technique with dressing changes The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection.

Multiple sclerosis

a chronic, progressive degenerative disorder of the CNS. Characterized by disseminated demyelination of nerve fibers in the brain and spinal cord

myasthenia gravis

an autoimmune disease of the neuromuscular junction. characterized by the fluctuating weakness of certain skeletal muscle groups, which increases with muscle use.

Guillain-Barre syndrome

autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response, and sudden muscle weakness

spinal shock

spinal shock presents with total flaccid paralysis and loss of all reflexes below the level of injury.

Spinal cord injury

temporary or permanent alteration in the function of the spinal cord, caused by trauma or damage to the spinal cord

Intracranial pressure

the amount of pressure inside the skull controlled by the three essential components of pressure in the skull: brain tissue, blood, CSF

neurogenic shock

unopposed PSNS stimulation and disruption of SNS, causing bradycardia, vasodilation, and hypotension. usually occurs with SCI at T6 or above

the nurse advises a patient with myasthenia gravis to A. perform physically demanding activities early in the day B. anticipate the need for weekly plasmapheresis treatments C. do frequent weight-bearing exercise to prevent muscle atrophy D. protect the extremities from injury due to poor sensory perception

A. perform physically demanding activities early in the day

What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? A. monitor fluid and electrolyte status carefully B. position the patient in a high Fowler's position C. administer vasoconstrictors to maintain cerebral perfusion D. maintain physical restraints to prevent episodes of agitation

A. monitor fluid and electrolyte status carefully

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? A. bradycardia B. hypertension C. neurogenic spasticity D. bounding pedal pulses

A. bradycardia Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension

Which conditions can lead to the development of a brain abscess? A. endocarditis B. ear infection C. tooth abscess D. skull fracture E. scalp laceration F. sinus infection

A. endocarditis B. ear infection C. tooth abscess D. skull fracture F. sinus infection

Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? A. headache and rising blood pressure B. irregular respirations and shortness of breath C. decreased level of consciousness or hallucinations D. abdominal distention and absence of bowel sounds

A. headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A. hypertension B. hyperlipidemia C. alcohol consumption D. oral contraceptive use

A. hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? A. maintain PaCO2 of approximately 35mmHg B. provide small doses of fentanyl via IV bolus for pain management C. measure body temperature every 1-2 hrs D. reposition the client every 2 hours

A. maintain PaCO2 of approximately 35mmHg The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure.

A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. maintenance of the patients airway B. positioning to promote cerebral perfusion C. control of fluid and electrolyte imbalances D. administration of tPA

A. maintenance of the patients airway

A nurse is assessing a client who has a head injury following a motor vehicle accident. The nurse should identify that which of the following findings indicates increasing ICP? A. restlessness B. dizziness C. hypotension D. fever

A. restlessness Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure.

The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? A. safety measures B. patience with communication C. mobility assistance on the right side D. place food in the left side of the patient's mouth

A. safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for (select all that apply.)? A. seizures B. vision loss C. cerebral edema D. pituitary dysfunction E. parathyroid dysfunction F. focal neurologic defects

A. seizures B. vision loss C. cerebral edema D. pituitary dysfunction F. focal neurologic defects

The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality? A. surgery B. chemotherapy C. radiation therapy D. biologic drug therapy

A. surgery

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)? A. ticlopidine B. clopidogrel C. enoxaparin D. dipyridamole E. enteric-coated aspirin F. tPA

A. ticlopidine B. clopidogrel D. dipyridamole E. enteric-coated aspirin

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell in her home. the provider determines that the client had an embolic stroke. Which of the following medications should the nurse administer? A. Tissue plasminogen activator B. Recombinant factor VIII C. Nitroglycerin D. Lidocaine

A. tissue plasminogen activatior a thrombolytic that should dissolve the clot that caused the stroke

Which care measure is a priority for a patient with multiple sclerosis (MS)? A. vigilant infection control and adherence to standard precautions B. careful monitoring of neurologic assessment and frequent orientation C. maintenance of a calorie count and hourly assessment of intake and output D. assessment of blood pressure and monitoring for signs of orthostatic hypotension

A. vigilant infection control and adherence to standard precautions Infection control is a priority in the care of patients with MS because infection is the most common cause of an exacerbation of the disease.

A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation (select all that apply.)? A. drink more milk B. Eat 20-30 g of fiber per day C. use oral laxatives everyday D. limit caffeinated beverages E. drink 1800-2800 mL of water or juice F. establish bowel evacuation time at bedtime

B. Eat 20-30 g of fiber per day D. limit caffeinated beverages E. drink 1800-2800 mL of water or juice

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? A. judgement B. eye opening C. abstract reasoning D. best verbal response E. best motor response F. cranial nerve function

B. eye opening D. best verbal response E. best motor response

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. impulsivity B. impaired speech C. left-sided neglect D. short attention span

B. impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

The nurse has administered a prescribed IV osmotic diuretic to an unconscious patient. which parameter should the nurse monitor to determine the medications effectiveness? A. blood pressure B. intracranial pressure C. oxygen saturation D. hemoglobin and hematocrit

B. intracranial pressure

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. Which additional findings would the nurse expect? A. an aura or focal seizure B. nystagmus or confusion C. abdominal pain or cramping D. irregular pulse or palpitations

B. nystagmus or confusion Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech.

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A. central cord syndrome B. spinal shock syndrome C. anterior cord syndrome D. brown sequard syndrome

B. spinal shock syndrome About 50% of people with acute spinal cord injury experience spinal shock, a temporary loss of reflexes, sensation, and motor activity.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. which of the following actions should the nurse take to help stimulate micturition? A. encourage the client to use the valsalva maneuver B. stroke the clients inner thigh C. perform the crede maneuver D. administer a diuretic

B. stroke the clients inner thigh The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation.

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? A. I can take the medication with food or milk B. the medication should be started 1 week after paralysis C. I can acetaminophen with the prescribed medications D. chances of a full recovery are good if I take the medication

B. the medication should be started 1 week after paralysis Prednisone should be started immediately. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs.

When establishing a diagnosis of multiple sclerosis (MS), which diagnostic tests will the nurse expect (select all that apply.)? A. EEG B. ECG C. CT scan D. Carotid duplex scan E. evoked response testing F. CSF analysis

C. CT scan E. evoked response testing F. CSF analysis

The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A. a 42 year old patient with MS who was admitted with sepsis B. a 72 year old patient with parkinson's disease who has aspiration pneumonia C. a 38 year old patient with myasthenia gravis who declined prescribed medications D. a 45 year old patient with amyotrphic lateral sclerosis who refuses enteral feedings

C. a 38 year old patient with myasthenia gravis who declined prescribed medications Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will experience myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.

The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A. serum potassium and serum sodium levels B. urine osmolality and urine specific gravity C. absolute neutrophil count and platelet count D. cerebrospinal fluid pressure and cell count

C. absolute neutrophil count and platelet count

Which nursing diagnosis is a priority in the care of a patient with myasthenia gravis (MG)? A. acute confusion B. bowel incontinence C. activity intolerance D. disturbed sleep pattern

C. activity intolerance

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? A. insert a rectal stimulant suppository B. teach the patient to gradually increase intake of high-fiber foods C. assess bowel movements for frequency, consistency, and volume D. instruct the patient to avoid all caffeinated and carbonated beverages

C. assess bowel movements for frequency, consistency, and volume The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury.

The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. document the ICP reading in the chart B. determine if the patient has a headache C. assess the patient's level of consciousness D. position the patient with the head elevated to 60 degrees

C. assess the patient's level of consciousness The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? A. support selection of a high-protein diet B. discuss options for sexuality and fertility C. assist in planning a prescribed bowel program D. use quad coughing to strengthen cough efforts

C. assist in planning a prescribed bowel program

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A. urinary catheterization B. check for bowel impaction C. elevate the head of the bed D. administer intravenous hydralazine

C. elevate the head of the bed Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.

A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? A. prevent UTI B. monitor patient every 15 minutes C. encourage him to verbalize his feelings D. teach him about using the gastrocolic reflex

C. encourage him to verbalize his feelings To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will likely need a wheelchair and have impaired sexual function. Resuming a racing career is unlikely. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult.

A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. high blood flow to the brain B. normal intracranial pressure C. impaired bloodflow to the brain D. adequate autoregulation of bloodflow

C. impaired bloodflow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

A nurse is assessing a client who had a right hemispheric stoke. Which of the following neurologic deficits should the nurse expect? A. aphasia B. right sided neglect C. impulsive behavior D. inability to read

C. impulsive behavior the nurse should expect impulsive behavior, poor judgment, and lack of awareness of neurologic deficits

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. hypoactive deep tendon reflexes B. ascending paralysis C. intention tremors D. increased lacrimation

C. intention tremors Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. which nursing intervention will be included in the plan of care? A. encourage coughing and deep breathing B. position the patient with knees and hips flexed C. keep the head of the bed elevated to 30 degrees D. cluster nursing interventions to provide rest periods

C. keep the head of the bed elevated to 30 degrees

The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? A. specific patient neurologic deficits B. the patient's ability to communicate C. rehabilitation potential of the patient D. presence of complications of a stroke

C. rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe, the ability of the patient to recover is most likely to positively impact the family's coping

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A. pain assessment B. glasgow coma scale C. respiratory assessment D. musculoskeletal assessment

C. respiratory assessment Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. overestimation of physical abilities B. difficulty judging position and distance C. slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C. slow and possibly fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A. seizure disorders may occur in weeks or months B. the family will be unable to cope with role reversals C. there are often residual changes in personality and cognition D. referrals will be made to eliminate residual deficits from the damage

C. there are often residual changes in personality and cognition In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept.

The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? A. giving the patient 1 oz of water to swallow B. telling the patient to perform a chin tuck before swallowing C. assisting the patient to sit in a chair before feeding the patient D. assessing cranial nerves III, IV, VI before attempting the feeding

D. Assessing cranial nerves III, IV, and VI before attempting feeding The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial nerves III, IV, and VI are responsible for ocular movements. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. a 92 year old female who takes warfarin for atrial fibrillation B. a 28 year old male patient who uses marijuana after chemotherapy to control nausea C. a 42 year old female patient who takes oral contraceptives and has migraine headaches D. a 72 year old male patient who has hypertension and diabetes mellitus and smokes tobacco

D. a 72 year old male patient who has hypertension and diabetes mellitus and smokes tobacco Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor, and smoking nearly doubles the risk of a stroke.

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. assist the patient to the bathroom every 2 hours B. provide incontinence briefs to wear during the day C. administer dulcolax rectal suppository every day D. arrange for several servings per day of cooked fruits and vegetables

D. arrange for several servings per day of cooked fruits and vegetables Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. take the person to the hospital if a headache lasts for more than 24 hours B. stroke symptoms usually start when the person is awake and physically active C. a person with a transient ischemic attack has mild symptoms that will go aware D. call 911 immediately if a person develops slurred speech or difficulty speaking

D. call 911 immediately if a person develops slurred speech or difficulty speaking

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? A. glasgow coma scale score of 15 B. intracranial pressure reading of 15mmHg C. ecchymosis at base of skull D. clear drainage from nose

D. clear drainage from nose clear drainage indicates that CSF is leaking from the skill fracture

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. the client reports a throbbing headache and nausea. the nurse notes facial drooping and a blood pressure of 220/110. Which of the following actions should the nurse take first? A. administer hydralazine via IV bolus B. loosen the clients clothing C. empty the client's bladder D. elevate the head of the client's bed

D. elevate the head of the client's bed indicate autonomic dysreflexia and they are at risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from supine to an upright position which will result in rapid postural hypotension.

A nurse is caring for a patient who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? A. assess hourly for a spike in blood pressure B. keep the client on bed rest C. keep a padded tongue blade at the bedside D. establish IV access

D. establish IV access The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock.

When planning care for a patient with a cervical spinal cord injury at C5, which nursing diagnosis has the highest priority? A. impaired urinary elimination related to tetraplegia B. risk for impaired tissue integrity related to paralysis C. disabled family coping related to the extent of trauma D. ineffective airway clearance related to cervical spinal cord injury

D. ineffective airway clearance related to cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Although all are appropriate nursing diagnoses for a patient with a cervical spinal cord injury, respiratory needs are always the highest priority (ABCs).

A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? A. free water should be avoided B. sodium restrictions can be managed C. dehydration can be better avoided with feedings D. malnutrition promotes continued cerebral edema

D. malnutrition promotes continued cerebral edema A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema.

A nurse is caring for a client who is recovering from a stroke and has right sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? A. check the clients cheek on his affected side after he eats to be sure no food remains there B. encourage the client to sit upright with his head tilted slightly forward during meals C. provide the client eating utensils that have large handles D. remind the client to look consciously at both sides of his meal tray

D. remind the client to look consciously at both sides of his meal tray Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food he is able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help him compensate for the visual loss.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A. tonic spasms of the legs B. curling in a fetal position C. arching of the neck and back D. resistance to flexion of the neck

D. resistance to flexion of the neck Nuchal rigidity is a clinical manifestation of meningitis.

A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? A. serum sodium of 120 mEq/L B. urine specific gravity of 1.001 C. fasting blood glucose of 80 mg/dL D. serum osmolality of 290 mOsm/kg

D. serum osmolality of 290 mOsm/kg Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.

The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? A. TIA B. embolic stroke C. thrombotic stroke D. subarachnoid hemorrhage

D. subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A. present several thoughts at once so that the patient can connect the ideas B. ask open-ended questions to provide the patient the opportunity to speak C. finish the patient's sentences to minimize frustration associate with slow speech D. use simple, short sentences accompanies by visual cues to enhance comprehension

D. use simple, short sentences accompanies by visual cues to enhance comprehension When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A. I want to be rehabilitated for my daughters wedding in 2 weeks B. Rehabilitation will be more work done by me alone to try to get better C. I will be able to do all my normal activities after I go through rehabilitation D. with rehabilitation, I will be able to function at my highest level of wellness

D. with rehabilitation, I will be able to function at my highest level of wellness

Autonomic hyperreflexia (dysreflexia)

Massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system Stimulation of the sensory receptors below the level of the cord lesion - HTN, bradycardia, pounding headache