CAI Week 10 quiz

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Assessment of respiratory rate and effort

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action should the nurse appropriately take?

Ask the patient to provide input for the plan of care.

Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

Assess fluid and dietary intake. The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Assist to plan a prescribed bowel program.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

Call the doctor if you experience pain or develop herpes lesions near the ear

What should the nurse advise a patient with myasthenia gravis (MG) to do?

Complete physically demanding activities early in the day

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Have you had a recent influenza infection?

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition?

Hypotension

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Hypotension Hyperthermia Absence of bowel sounds

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

I am using the modified feeding utensils at every meal. I still spill, but I am getting better.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond?

MS symptoms may worsen after the pregnancy

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response?

Multiple options are available to maintain sexuality after spinal cord injury.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1

Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)?

Performing passive ROM to extremities

A 60 y.o. female was just diagnosed with Parkinson's disease. The priority nursing intervention is:

Promoting physical exercise and a well-balanced diet

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury?

Propel a manual wheelchair on a flat surface. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse's best response?

Respect the patient's feelings and arrange for privacy at mealtimes

A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?

Triggers leading to facial discomfort

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?

Uncontrolled head movement**

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

cheddar cheese

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?

decreased tremors

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

teach the patient how to use the Crede method.