PCC3 exam 2 practice questions

why do patients have to empty their bladder before lumbar puncture?

- full bladder increases ICP - allows to relieve a distended bladder - they will be lying or sitting still for a long time

initial action for a patient with a cervical spine injury with a throbbing headache, nausea, and increased blood pressure?

HOB elevated & palpate the bladder

the nurse is evaluating the neuro signs of a client in spinal shock following spinal cord injury. which observation indicates that spinal shock persists? a. hyperreflexia b. positive reflexes c. flaccid paralysis d. reflex emptying of the bladder

c - resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care? a. Fracture b. Malabsorption c. Delirium d. Anemia

a - Older adults who have impaired mobility due to a health problem or injury are at risk for complications of immobility, such as osteoporosis (bone loss) which leads to fracture. Being an older woman increases that risk due to loss of estrogen to protect bone loss. The other choices are not problems of immobility. Delirium is possible but is more common in clients over 70 years of age.

You're maintaining an external ventricular drain. The ICP readings should be?* A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg

a

A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the nurse to contact the primary health care provider? a. Shingles infection on the client's back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea

a - An LP would not be performed if the client has a skin infection at or near the puncture site because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary health care provider if shingles were identified on the client's back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the client's needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."

a - Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.

The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language

a - CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

a - Clients who have multiple sclerosis often have muscle spasticity which may be reduced by drug therapy, such as baclofen. While massage and assistance with self-care may be helpful, these interventions are not the most effective and therefore not the most appropriate in managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle spasms, some client are candidates for deep brain stimulation as a last resort.

Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand."

a - Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client where different food items are on the meal tray. The other options are not appropriate for client with cranial nerve II impairment.

A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever

a - Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.

You're assessing a patient's health history for risk factors associated with developing Guillain-Barré Syndrome. Select all the risk factors below: A. Recent upper respiratory infection B. Patient's age: 3 years old C. Positive stool culture Campylobacter Jejuni D. Hyperthermia E. Epstein-Barr F. Diabetes G. Myasthenia Gravis

a, c, e - Risk factors for developing Guillain-Barré Syndrome include: experiencing upper respiratory infection, GI infection (especially from Campylobacter Jejuni), Epstein-Barr infection, HIV/AIDS, vaccination (flu or swine flu) etc.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

a - Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.

a - The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.

How would the nurse document this finding? (patient lying with hands in to the core, legs extended, supine) a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration

a - The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The primary health care provider, the charge nurse/team leader, and other health care team members would be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

a - The client with a cervical or high thoracic spinal cord injury typically has weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and helps prevent atelectasis and other respiratory problems. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client would be encouraged to cough and clear secretions, and placed in high-Fowler position to prevent aspiration.

What is the BEST position for a patient experiencing autonomic dysreflexia? A. High Fowler's with legs lowered B. Low Fowler's with legs lowered C. Semi-Fowler's with legs at heart level D. Prone

a - The patient should be in high Fowler's (90 degrees) with the legs lowered. This will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.

You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature?* A. Rectal B. Oral C. Axillary

a - This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.

Which of the following is contraindicated in a patient with increased ICP?* A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

a - can cause brain herniation

a nurse is caring for a client who experienced a cervical spine injury 3 months ago. the nurse should plan to implement which of the following types of bladder management methods? a. condom catheter b. intermittent urinary catheterization c. crede's method d. indwelling urinary catheter

a - implement the noninvasive use of a CC because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder

a nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscles control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? a. prevention of further damages to the spinal cord b. prevention of contractors of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

a - the greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. when planning care, the priority intervention to take is to prevent further damage to the spinal cord by minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure

a, b - A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.

The nurse would recognize which signs and symptoms as consistent with brainstem tumors? (Select all that apply.) a. Hearing loss b. Facial pain c. Nystagmus d. Vomiting e. Hemiparesis

a, b, c - Hearing loss (CN VIII), facial pain (CN V), and nystagmus (CN III, IV, and VI) all are indicative of a brainstem tumor because these cranial nerves originate in the brainstem. Vomiting and hemiparesis are more indicative of cerebral tumors.

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

a, b, c, e - These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

a, b, d, e

A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Decreasing level of consciousness

a, b, e - The nurse would urgently communicate changes in a patient's neurologic status, including a decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.

A patient with Guillain-Barré Syndrome has a feeding tube for nutrition. Before starting the scheduled feeding, it is essential the nurse? Select all that apply: A. Assesses for bowel sounds B. Keeps the head of bed less than 30' degrees C. Checks for gastric residual D. Weighs the patient

a, c - Some patients who experience GBS will need a feeding tube because they are no longer able to swallow safely due to paralysis of the cranial nerves that help with swallowing. GBS can lead to a decrease in gastric motility and paralytic ileus. Therefore, before starting a scheduled feeding the nurse should always assess for bowel sounds and check gastric residual.

Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater

a, c, d - Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a, c, d - Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.

a, c, d - Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.

You're teaching a group of nursing students about Guillain-Barré Syndrome and how it can affect the autonomic nervous system. Which signs and symptoms verbalized by the students demonstrate they understood the autonomic involvement of this syndrome? Select all that apply: A. Altered body temperature regulation B. Inability to move facial muscles C. Cardiac dysrhythmias D. Orthostatic hypotension E. Bladder distension

a, c, d, e - All these are some signs and symptoms that can present in severe cases of GBS when the autonomic nervous system is involved.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

a, c, d, f - information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments would be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply: A. Headache B. Low blood glucose C. Sweating D. Flushed below site of injury E. Pale and cool above site of injury F. Hypertension G. Slow heart rate H. Stuffy nose

a, c, f, g, h - All of these are signs and symptoms of autonomic dysreflexia. The patient will have flushing above site of injury due to vasodilation from parasympathetic activity, BUT will be pale and cool below site of injury due to vasoconstriction occurring below the site of injury for the sympathetic response reflex.

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

a, d, e, f - Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.

A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.) a. Place the client in a flat position. b. Monitor vital signs for hypotension. c. Utilize a bedside commode. d. Assess for abdominal distension. e. Report the leak to the surgeon.

a, e - If cerebrospinal fluid (CSF) is leaking from a surgical wound, the nurse would place the client in a flat position and contact the surgeon for repair of the leak. Hypotension and abdominal distension are not complications of CSF leakage.

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as:* A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

b

The patient's lumbar puncture results are back. Which finding below correlates with Guillain-Barré Syndrome?* A. high glucose with normal white blood cells B. high protein with normal white blood cells C. high protein with low white blood cells D. low protein with high white blood cells

b

You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

b

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis

b - A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs.

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?* A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

b - All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?* A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

b - Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.

Which patient below is at MOST risk for developing a condition called autonomic dysreflexia? A. A 24-year-old male patient with a traumatic brain injury. B. A 15-year-old female patient with a spinal cord injury at C7. C. A 35-year-old male patient with a spinal cord injury at L6. D. A 42-year-old male patient recovering from a hemorrhagic stroke.

b - Patients who are at MOST risk for developing autonomic dysreflexia are patients who've experienced a spinal cord injury at T6 or higher...this includes C7. L6 is below T6, and traumatic brain injury and hemorrhagic stroke does not increase a patient risk of AD.

Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.

b - Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.

In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury? A. Flushed lower body B. Pale and cool lower extremities C. Low blood pressure D. Absent reflexes

b - The answer is B. The lower extremities would be cool and pale due to vasconstriction caused by the exaggerated reflex response of the sympathetic nervous system from an irritating stimulus. The sympathetic reflex can NOT be unopposed by the parasympathetic nervous system due to the spinal injury, which is blocking the nerve impulse. The areas found ABOVE the site of injury would be flushed due to vasodilation from parasympathetic stimulation.

When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose

b - The client is categorized as being lethargic because he or she can be easily aroused even though drowsy. The nurse would carefully monitor the client to determine any decrease in the level of consciousness (LOC).

A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which complication of this procedure would alert the nurse to urgently contact the primary health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest

b - The nurse would immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

A 25 year-old presents to the ER with unexplained paralysis from the hips downward. The patient explains that a few days ago her feet were feeling weird and she had trouble walking and now she is unable to move her lower extremities. The patient reports suffering an illness about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barré Syndrome and orders some diagnostic tests. Which finding below during your assessment requires immediate nursing action? A. The patient reports a headache. B. The patient has a weak cough. C. The patient has absent reflexes in the lower extremities. D. The patient reports paresthesia in the upper extremities.

b - The patient's signs and symptoms in this scenario are typical with Guillain-Barré Syndrome. The syndrome tends to start in the lower extremities (with paresthesia that will progress to paralysis) and migrate upward. The respiratory system can be affected leading to respiratory failure. Therefore, the nurse should assess for any signs and symptoms that the respiratory system may be compromised (ex: weak cough, shortness of breath, dyspnea...patient says it is hard to breath etc.). The nurse should immediately report this to the MD because the patient may need mechanical ventilation. Absent reflexes is common in GBS and paresthesia can extend to the upper extremities as the syndrome progresses. A headache is not common.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

b - This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

You're educating a patient about treatment options for Guillain-Barré Syndrome. Which statement by the patient requires you to re-educate the patient about treatment? A. "Treatments available for this syndrome do not cure the condition but helps speed up recovery time." B. "Plasmapheresis or immunoglobin therapies are treatment options available for this syndrome but are most effective when given within 4 weeks of the onset of symptoms." C. "When I start plasmapheresis treatment a machine will filter my blood to remove the antibodies from my plasma that are attacking the myelin sheath." D. "Immunoglobulin therapy is where IV immunoglobulin from a donor is given to a patient to stop the antibodies that are damaging the nerves.

b - This statement is incorrect. Plasmapheresis and immunoglobin therapies are treatment options available for GBS, BUT they are only really effective when given within 2 weeks from the onset of symptoms (not 4 weeks).

the nurse is caring for the client with increased intracranial pressure. the nurse would note which trend in vital signs if the intracranial pressure is rising? a. increasing temperature, increasing pulse, decreasing blood pressure b. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure d. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

b - a change in vital signs may be a late sign of increased ICP. trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

a nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110mmHg and apical HR 54bpm. which of the following actions should the nurse take first? a. examine skin for irritation or pressure b. sit the client upright in bed c. check the urinary catheter for blockage d. administer antihypertensive medication

b - autonomic dysflexia first action

the nurse is assessing the motor and sensory function of an unconscious client. the nurse should use which technique to test the client's peripheral response to pain? a. sternal rub b. nail bed pressure c. pressure on the orbital rim d. squeezing of the sternocleidomastoid

b - nail bed pressure tests a basic motor and sensory peripheral response. cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid.

the nurse has completed discharge instructions for a client with application of a halo device. which statement indicates that the client needs further clarification of the instructions? a. I will use a straw for drinking b. I will drive only during the daytime c. I will be careful because the device alters balance d. I will wash the skin daily under the lamb's wool liner of the vest

b - the halo device alters balance and can cause fatigue because of its weight. the client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid using lotion or powders. the liner should be changed if odor is a problem. the client should have food cut into small pieces and drink with a straw. pin care is done as instructed. the client cannot drive at all because the device impairs the range of vision.

Which statements are TRUE about autonomic dysreflexia? Select all that apply: A. "Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury." B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension." C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury." D. "The first-line of treatment for autonomic dysreflexia is an antihypertensive medication."

b, c - Option A is false, it should say: Autonomic dysreflexia is an exaggerated reflex response by the SYMPATHETIC (NOT parasympathetic) nervous system that results in severe hypertension due to a spinal cord injury. Option D is false because medications are used only if the blood pressure is not decreasing or the cause cannot be determined.

You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service: A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

b, c, d, e - Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and the parasympathetic system is unable to oppose it. This will lead to severe hypertension. The most common cause of AD is a bladder issue (full/distended bladder, urinary tract infection etc). Other common causes are due to a bowel issue like fecal impaction or skin break down (pressure injury/ulcer, cut, infection etc.).

a client with a spinal cord injury is prone to experiencing autonomic dysreflexia. the nurse should include which measure in the plan of care to minimize the risk of recurrence? (SATA) a. ensuring the client has a bowel movement at least once a week b. keeping the linen wrinkle free under the client c. avoiding unnecessary pressure on the lower limbs d. limiting bladder catheterization to once every 12 hours e. turn and reposition the client at least every 2 hours

b, c, e - the most frequent cause of autonomic dysreflexia is a distended bladder. straight cauterization should be done every 4-6 hours, and urinary catheters should be checked frequently to prevent kinks in the tubing. constipation and fecal impaction are other causes, so maintaining bowel regularity is important. other causes include stimulation of the skin from tactile, thermal, or painful stimuli.

priority assessment findings for a client with head trauma? a. eyes that move opposite direction when head is turned b. extremities contracted to core c. fixed pupils that remain 8mm when light flashed on them d. LOC undiminished since admission e. grips 5/5 bilaterally f. toes that fan when sole is stroked

b, c, f

Your patient is back from having a lumbar puncture. Select all the correct nursing interventions for this patient?* A. Place the patient in lateral recumbent position. B. Keep the patient flat. C. Remind the patient to refrain from eating or drinking for 4 hours. D. Encourage the patient to consume liquids regularly.

b, d - The patient will need to stay flat after the procedure for a prescribed amount of time to prevent a headache, and the nurse will need to encourage the patient to drink fluids regularly to help replace the fluid lost during the lumbar puncture.

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

b, d - These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).

A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.

b, d, e - Clients who have mild traumatic brain injuries should take acetaminophen for headache. An allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The patient laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the patient's oral fluid intake. e. Assess the chest and back for skin breakdown.

b, e - The nurse would assess the pin sites for signs of infection or loose pins. The nurse would also assess the client's chest and back for skin breakdown from the halo vest. The vest is not removed for bathing and the pins are not intentionally loosened.

After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition? A. Skin break down B. Blood glucose C. Possible bladder irritant D. Last bowel movement

c - A bladder issue is usually the most common cause of AD. If this isn't the issue the nurse should assess the bowel and then the skin for break down.

A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment

c - Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

c - An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis.

You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST? A. Reassess the patient's blood pressure. B. Check the patient's blood glucose. C. Position the patient at 90 degrees and lower the legs. D. Provide cooling blankets for the patient.

c - Based on the patient findings and how the patient has a spinal cord injury at T6, they are experiencing autonomic dysreflexia. Patients with this condition may have a blood pressure that is 20-40 mmHg higher than their baseline and may experience bradycardia (heart rate less than 60). The FIRST action the nurse should take when AD is suspected is to position the patient at 90 degree (high Fowler's) and lower the legs. This will allow gravity to cause the blood to pool in the lower extremities and help decrease the blood pressure. Then the nurse should try to find the cause of the autonomic dysreflexia, which could be a full bladder, impacted bowel, or skin break down.

A nurse asks a client to take deep breaths during an electroencephalography (EEG). The client asks, "Why are you asking me to do this?" How would the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures."

c - Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other responses are not accurate.

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine

c - Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP.

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?* A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

c - It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?* A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

c - Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let your primary health care provider know." b. "Rehabilitation programs have helped many patients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

c - Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocke

c - The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this client's assessment using the Glasgow Coma Scale shown below? a. 8 b. 10 c. 12 d. 14

c - The client opens his eyes to speech (Eye Opening: To sound = 3), mumbles in response to questions (Verbal Response: Inappropriate words = 3), and follows simple commands (Motor Response: Obeys commands = 6). Therefore, the client's Glasgow Coma Scale score is 3 + 3 + 6 = 12.

A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

c - The occupational therapist instructs the patient in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with other issues.

You're about to send a patient for a lumbar puncture to help rule out Guillain-Barré Syndrome. Before sending the patient you will have the patient?* A. Clean the back with antiseptic B. Drink contrast dye C. Void D. Wash their hair

c - The patient will need to void and empty the bladder before going for a LP. This will help decrease the chances of the bladder becoming punctured during the procedure.

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:* A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

c - These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? A. Perform a bladder scan B. Perform a rectal digital examination C. Assess the patient's blood pressure D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.

c - This is the nurse's NEXT action. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient's blood pressure. If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.

a client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. which strategy should the nurse incorporate in the plan of care to help the client cope with the illness. a. give the client full control over care decisions and restricting visitors b. providing positive feedback and encouraging active range of motion c. providing information, giving feedback, and encouraging relaxation d. providing IV administered sedatives, reducing distractions, and limiting visitors

c - the client with GBS experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. the nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback, and encouraging relaxation and distraction. to the client. the family can become involved with selected care activities and provide diversion for the client as well.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

c, d, e - Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

Which tests below can be ordered to help the physician diagnose Guillain-Barré Syndrome? Select all that apply: A. Edrophonium Test B. Sweat Test C. Lumbar puncture D. Electromyography E. Nerve Conduction Studies

c, d, e - These are the tests that can be ordered to help the MD determine if the patient is experiencing GBS.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Reposition the client off of the reddened areas. d. Get the client out of bed and into a chair several times a day. e. Apply a pressure-reducing mattress.

c, e - Appropriate interventions to relieve pressure on the reddened areas include frequent repositioning, using a pressure-reducing mattress, and having the client sit in a chair to remove pressure from the hips and sacrum. Correct sitting position would allow the pressure to be on both ischial tuberosities. ROM exercises are used to prevent contractures.

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board

d - A client who has a complete cervical spinal cord injury is unable to use any extremity except for parts of the hands and possibly the lower arms. Therefore, the client would be unable to use any of these ambulatory aids except for a sliding board, also known as a slider, which provides a "bridge" between the bed and a chair. The client uses his or her arms in a locked position to support the body while moving slowly across the board.

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented x3 d. Decreasing level of consciousness

d - A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild headache would be expected for a client having a TBI. Equal reactive pupils and being alert and oriented are normal assessment findings

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)

d - A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician?* A. The patient's blood pressure is 130/80. B. The patient reports a throbbing headache. C. The patient's lower extremities are pale and cool. D. The patient states they took Sildenafil 12 hours ago.

d - A patient should not receive a dose of Nitropaste if they have taken a phosphodiesterase inhibitor within the past 24 hours (Sildenafil or Tadalafil). This will cause major vasodilation and severe hypotension that will not respond to medication. Another medication should be used. All the other findings are expected with autonomic dysreflexia.

While positioning a patient in bed with increased ICP, it important to avoid?* A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

d - Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP.

the client is admitted to the hospital with a diagnosis of Guillian-Barre syndrome. which past medical history finding makes the client most at risk for this disease? a. meningitis or encephalitis during the last 5 years b. seizures or trauma to the brain within the last year c. back injury or trauma to the spinal cord during the last 2 years d. respiratory or GI infection during the previous mouth

d - GBS is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. many clients report history of respiratory or GI infection in the 1-4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

During nursing report you learn that the patient you will be caring for has Guillain-Barré Syndrome. As the nurse you know that this disease tends to present with: A. signs and symptoms that are unilateral and descending that start in the lower extremities B. signs and symptoms that are symmetrical and ascending that start in the upper extremities C. signs and symptoms that are asymmetrical and ascending that start in the upper extremities D. signs and symptoms that are symmetrical and ascending that start in the lower extremities

d - GBS signs and symptoms will most likely start in the lower extremities (ex: feet), be symmetrical, and will gradually spread upward (ascending) to the head. There are various forms of Guillain-Barré Syndrome. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most common type in the U.S. and this is how this syndrome tends to present.

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How would the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you really have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Can you tell me more about what worries you, so we can see if we can do something to make adjustments?"

d - Investigate specific concerns about situational or role changes before providing additional information. The nurse would not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the patient. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which statement indicates client understanding of the teaching? a. "I must increase my fluids because of the dye used for the MRI." b. "My urine will be radioactive so I should not share a bathroom." c. "My gag reflex will be tested before I can eat or drink anything." d. "I can return to my usual activities immediately after the MRI."

d - No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the client's urine would not be radioactive. The procedure does not impact the client's gag reflex.

A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.

d - The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required.

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d - The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.

d - This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.

The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to? A. Avoid using lubricants B. Stimulate the bowel with rectal manipulation C. Slowly administer a saline solution prior to assessment D. Instill an anesthetic jelly prior to assessment

d - To avoid increasing autonomic dysreflexia symptoms by increasing the sympathetic reflex due to an irritating stimulus, the nurse should instill an anesthetic jelly before assessing the rectum for hardened stool. This is also important prior to catheterization to check the bladder for urine.

a client recovery from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? a. blowing the nose b. isometric exercises c. coughing vigorously d. exhaling during repositioning

d - activities that increase intra-thoracic and intra-abdominal pressures cause in indirect elevation of the intracranial pressure. some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intra-thoracic pressure from rising.

a client has clear fluid leaking from the nose following a basilar skull fracture. which finding would alert the nurse that cerebrospinal fluid is present? a. Fluid is clear and tests negative for glucose. b. Fluid is grossly bloody in appearance and has a pH of 6. c. Fluid clumps together on the dressing and has a pH of 7. d. Fluid separates into concentric rings and tests positive for glucose.

d - leakage of CSF from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called halo signs. the fluid also tests positive for glucose.

a nurse is caring for a client who experienced a cervical spine injury 24 hours ago. which of the following prescriptions should the nurse clarify with the provider? a. anticoagulant b. plasma expanders c. H2 antagonists d. muscle relaxants

d - the client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time

the nurse is admitting a client with Guillian-Barre syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? a. nebulizer and pulse oximeter b. blood pressure cuff and flashlight c. flashlight and incentive spirometer d. electrocardiographic monitoring electrodes and intubation tray

d - the client with GBS is at risk for respiratory failure because of ascending paralysis. an intubation tray should be available for use. another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of EKG monitoring. because the client is immobilized, the nurse should assess for DVT and PE routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

a nurse is caring for a client who has a C4 spinal cord injury. the nurse should recognize the client is at greatest risk for which of the following complications? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

d - when using ABC's approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

True or False: Guillain-Barré Syndrome occurs when the body's immune system attacks the myelin sheath on the nerves in the central nervous system.

false - Guillain-Barré Syndrome is an autoimmune neuro condition where the immune system attacks the nerves (myelin sheath) in the PERIPHERAL NERVOUS SYSTEM and cranial nerves. This condition does NOT occur in the central nervous system (CNS).

initial action for a client found on the floor who is lethargic, bleeding, HR-45, and BP-220/88?

spine immobilization and CT scan to rule out intracranial bleed