MEDSURG II PRINCIPLES WEEK 1
The lab calls to report the results of a cerebral spinal fluid analysis. Which of the following results should be immediately reported to the physician?
ANSWER: The presence of red blood cells. RATIONALE: Cerebral spinal fluid is clear and has a small amount of white blood cells but no red blood cells
The nurse is evaluating a 47-year old male client with a left ankle sprain. Which of the following medications would not be indicated for inflammation?
ANSWER: Tylenol (acetaminophen) RATIONALE:Acetaminophen does not have anti-inflammatory properties
A client has a history of chronic pain and is seeking pain management. Which of the following questions best helps the nurse to fully understand the clients pain?
ANSWER:Can you tell me how your pain has impacted your life? RATIONALE:A comprehensive pain assessment includes duration (includes when it started), type (incudes intensity, associated factors, influencing factors (what makes it better or worse), location
A client was recently admitted to the emergency department after falling down a flight of stairs. The client is complaining of nausea along with a headache and requests pain medication. The nurse observes that the client is restless. Which of the following actions by the nurse is a priority?
ANSWER:Check the client's visual acuity RATIONALE:Classic signs of increased intracranial pressure includes restlessness, decreased visual acuity, headache, nausea and vomiting, papilledema, changes in level of consciousness and seizures
The nurse is reading over the nurse's notes from the previous shift and comes across an entry that states "client was able to perform serial sevens". What is the significance of this statement in the care of the client with head trauma?
ANSWER:Cognitive function is not impaired. RATIONALE:Perform the serial 7's to assess cognitive function and damage to the frontal cortex
The nurse is providing an in-service on rectal medication administration. Which of the following would be included? Select all that apply:
ANSWER:Do not administer medications rectally for patients with thrombocytopenia RATIONALE:Avoid the rectal route for medication administration for patients who are thrombocytopenic
The nurse is preparing a 42 year old female client for an MRI of the head. Which of the following actions by the nurse is a priority?
ANSWER:Evaluate for the presence of an internal defibrillator. RATIONALE:MRIs are contraindicated for patients who have aneurysm clips, pacemakers, and internal defibrillators
The nurse is admitting a client with Meniere's disease who is experiencing severe vertigo. Which of the following actions does the nurse take next?
ANSWER:Initiate fall precautions RATIONALE:Clinical manifestations of vertigo include a spinning sensation, lightheadedness, loss of balance, nausea and vomiting
A male client is scheduled for a CT of the head with contrast. Which of the following actions should the nurse perform prior to the scan?
ANSWER:Notify the physician if the creatinine is elevated. RATIONALE:Contrast medium is nephrotoxic and is contraindicated if the patient has allergies to iodine, shellfish, or seafood, is pregnant or has an elevated creatinine
The nurse is caring for a client with a closed head injury. The client is lethargic and complains of a headache. Which of the following clinical manifestations suggests a worsening head injury.
ANSWER:The client is somewhat obtunded RATIONALE:Signs of a head injury that's worsening includes changes in level of consciousness, worsening headache, abnormal pupil response, vomiting, weakness, slurred speech or irritability
The nurse is caring for a client who has been a quadriplegic for 10 years. Which of the following interventions is priority? Answer: Reposition the client every 2 hours while in bed. RATIOANLE: Help to maintain skin integrity by turning and positioning every 2 hours and repositioning every hour when in a chair
A client complains of weakness, and drooping of the left shoulder. Which of the following actions should the nurse take next? Answer: Assess cranial nerve XI. RATIONALE: Have the patient shrug their shoulders or turn their head to the side against resistance to assess cranial nerve XI
A nurse is caring for a client with a closed head injury and notes that bowel sounds are absent. To minimize the risk of complications related to absent bowel sounds, which action would the nurse perform next? Answer: Avoid giving the client food or fluids by mouth. RATIONALE: Regurgitation and aspiration can occur following a head injury due to a decrease in gastric motility ;
A client is admitted to the intensive care unit with an acute spinal cord injury. The nurse believes that the client is experiencing neurogenic shock. Which of the following clinical manifestations supports this finding? Answer: A drop in blood pressure to 88/64. RATIONALE: Neurogenic shock results in hypotension, bradycardia and a decrease in cardiac output which could lead to death
A client is admitted to the emergency department with a closed head injury. The nurse knows that when performing a Glasgow Coma assessment, which of the following is assessed? Answer: Best eye, motor and verbal response RATIONALE: Conduct a Glascow Coma Scale to assess a patient's best motor, verbal and eye opening response
A client is diagnosed with a venous thromboembolus (VTE) in the left leg. He asks the nurse to massage the area to help decrease the pain. Which of the following responses by the nurse is the most appropriate? Answer: I will discuss alternative methods to decrease your pain with your physician. RATIONALE: Avoid massaging the calf or thigh since this could cause thrombus dislodgement
A client with a history of Bell's Palsy complains of left sided facial droop and is otherwise asymptomatic. Which action by the nurse is appropriate? Answer: Assess the function of cranial nerve VII. RATIONALE: Note facial symmetry by having the patient peform different facial expressions when assessing cranial nerve VII
A client presents to the emergency department following a motor vehicle accident. X-rays reveal a vertebral fracture. Which of the following interventions should the nurse perform in the setting of spinal shock? Answer: Insertion and maintenance of a nasogastric tube. RATIONALE: Provide intestinal decompression and intermittent catheterization (or indwelling catheter) in the setting of spinal shock
To prevent disuse syndrome which of the following interventions is a priority when planning the care of a client with quadraplegia? Answer: Provide range of motion exercises. RATIONALE: Provide patients with tetraplegia or quadriplegia with range of motion exercises at least four times a day to prevent disuse syndrome and contractures
A client who had a cerebral angiogram performed just returned to the unit. Which of the following interventions would help to minimize the risk of post procedural complications? Answer: Encourage oral fluid intake. RATIONALE: Provide fluids after using intravenous contrast to facilitate renal clearance of the agent
A client who had a fractured femur is being treated with skeletal traction. Which nursing intervention is a priority when caring for this client? Answer: Allow all of the weights to hang from the pulley freely. RATIONALE: Make sure the weights hang freely during traction
A client who had a myelogram performed just returned to the unit. Post procedure care should include which of the following interventions? Answer: Monitor for headache and nuchal rigidity. RATIONALE: Maintain the head of bed at 30-45 degrees for 3 hours following a myelogram and note any signs of meningitis (headache, nuchal rigidity, photophobia, seizures, fever)
A client with Meniere's disease complains of bilateral tinnitus. Which action should the nurse perform next? Answer: Perform a whisper test RATIONALE: Perform a whisper test to assess cranial nerve # VIII
A client who has Amyotrophic Lateral Sclerosis is being assessed by the nurse. Which cranial nerve would the nurse assess when evaluating the client's ability to form a bolus while eating. Answer: XII RATIONALE: Note whether the tongue is midline when protruding from the mouth to assess cranial nerve XII
A client complains of right facial numbness for 2 days and is otherwise asymptomatic. Which action by the nurse is appropriate? . Correct Answer: Test the ability to feel sensation to the face. RATIONALE: Touch the face with a sharp or dull object to assess cranial nerve V
A client who sustained a traumatic head injury has an intracranial bleed and is unresponsive. Which of the following nursing interventions would help to decrease intracranial pressure? Correct Answer: Maintain the head of the bed at a 30 degree angle. RATIONALE: Reduce increased intracranial pressure by elevating the head of the bed to 30 degrees (promote venous outflow from the brain), suctioning to prevent couging on secretions, decreasing cerebral edema (mannitol), keeping the head neutral, and maintaining ventilation (monitor arterial blood gas values)
A nurse is caring for a client who was in a motor vehicle accident and has a hematoma to the frontal region of the head. Which of the following findings is a potential complication from the injury? Answer: Complaints of vomiting. RATIONALE: Aspiration and regurgitation can occur following a head injury due to a decrease in gastric motility
A client with a traumatic brain injury was unconscious but is now awake. After performing a cranial nerve assessment the nurse notes that cranial nerve #IX and X are impaired. Which of the following actions would the nurse take next? Answer: Avoid giving the client anything by mouth. RATIONALE: Cranial nerve dysfunction (IX and X) could increase the risk for aspiration
A nurse is caring for a client with Parkinson's disease. The wife asks why he has such difficulty with moving. Which of the following is the most appropriate response by the nurse? Answer: He has a decreased amount of a neurological chemical which makes moving difficult. RATIONALE: With Parkinson's disease there is a decrease in dopamine levels which impairs voluntary movements
A nurse is caring for a client who had a lumbar discectomy. The nurse is preparing to administer hydromorphone (Dilaudid). Which of the following is a contraindication for this medication? Answer: Respiratory rate of 8 RATIONALE: Opioids produce undesirable effects such as constipation, nausea, pupil constriction and respiratory depression ;
A nurse is preparing the client for a lumbar puncture. The client expresses concerns about having a headache after the procedure. Which response by the nurse is most appropriate? Answer: You will be placed in a prone position to minimize the risk of a headache. RATIONALE: To avoid post lumbar headaches a small-gauge needle is used and the patient is placed in a prone position following the procedure(6 hours prone if more than 20ml of cerebral spinal fluid is removed)
A nurse is caring for a client who presents with an epidural hematoma and is unresponsive. When developing a plan of care, which of the following nursing diagnoses is a priority? Answer: Potential for impaired respiratory effort related to decreased cerebral perfusion. RATIONALE: Respiratory arrest can occur in minutes following an epidural hematoma since arterial hemorrhage may occur
Following a motorcycle collision, a client sustains a head injury and is being sent to the operating room for an intracranial bleed. Mannitol has been ordered. Prior to administering this medication, the nurse notes the following vital signs: Blood pressure: 156/44, Pulse 51, Respiratory rate: 12 breaths/minute. Which action should the nurse implement? Answer: Administer the scheduled dose of mannitol as prescribed. RATIONALE: Mannitol is an osmotic diuretic and helps to decrease fluid in the brain
A nurse is caring for a client with a spinal cord injury. Which of the following nursing interventions best helps the client to cope with their self care deficits? Answer: Allow the client to be as independent as possible. RATIONALE: Keep patients with self care deficits as independent as possible
A nurse is caring for a client with an acute spinal cord injury. Which of the following interventions should be included in the plan of care to ensure proper body alignment? Answer: Place a trochanter roll on the side of the legs. RATIONALE: Apply trochanter rolls to immobile patients to prevent external rotation
A nurse is caring for a client with an acute spinal cord injury. Which of the following interventions is an effective way to prevent a venous thromboembolus? Answer: Apply sequential teds to the bilateral lower extremities. RATIONALE: Prevent a pulmonary embolism or deep vein thrombosis by using anticoagulants, anti-embolism stockings and/or sequential teds ; Page#
A nurse is caring for a client with left sided hemiplegia following an acute cerebral vascular accident. Which of the following clinical manifestations is most consistent with a pulmonary embolism?
ANSWER: Tachypnea RATIONALE: Clinical manifestations of pulmonary embolism consist of chest pain, cough, dyspnea, hypoxemia, tachycardia, tachypnea, petechiae and restlessness
An experienced nurse is overseeing a graduate nurse using the Wong-Baker FACES scale. Which of the following confirms the graduate nurse understands proper use of the scale.
ANSWER: The graduate nurse will ask the client to point to the face that best reflects their pain intensity RATIONALE:The Wong-Baker FACES scale (ages 3 and up) consists of cartoon faces that the patient selects to report their pain.
Which of the following clinical manifestations indicate an impairment in the central nervous system?
ANSWER: 4+ deep tendon reflexes with sustained clonus. RATIONALE: A 4+ deep tendon reflex with sustained clonus always indicates central nervous system impairment
Which of the following findings require the nurse to notify the physician prior to a cerebral angiography?
ANSWER: A weak bilateral dorsalis pedis pulse of 1+. RATIONALE: Renal function and pulses must be noted prior to cerebral angiography since contrast medium is used
The nurse is preparing to start a 48-year old male with Parkinson's disease (PD) on a dopamine agonist. The nurse knows that dopamine has which of the following effects?
ANSWER: Affects movement RATIONALE:Dopamine is typically inhibitory and affects behavior and fine movement
A client with increased intracranial pressure has a sodium of 125 mEq/L. Which of the following is a possible cause of this electrolyte finding?
ANSWER: An increased secretion of antidiuretic hormone RATIONALE: An excessive increase in antidiuretic hormone (vasopressin) will result in a decrease in serum sodium levels (hyponatremia)
A client presents to the emergency department after being involved in a motor vehicle collision. The client was unconscious when the paramedics arrived at the scene and is now stuporous. These symptoms are consistent with which of the following injuries?
ANSWER: Brain contusion RATIONALE: Brain contusions are associated with loss of consciousness, stupor or confusion
The client presents to the emergency department reporting severe bone pain for several months. The client states that the oral OxyContin (oxycodone) and Celebrex (celecoxib) medication have not been working. Which of the following processes would most likely occur from unrelieved acute pain?
ANSWER: Increase in liver secretion of glucagon and decrease in pancreas secretion of insulin RATIONALE: Unrelieved pain increases glucagon production, decreases insulin secretion, depresses immune function, and can lead to addictive behaviors ; Page#
The nurse is caring for a client who received 70 stitches to repair a significant wound from a skateboarding accident. What would the nurse expect to find when assessing the laceration?
ANSWER: Inflammation RATIONALE: Prostaglandins initiate inflammation and contribute to tissue swelling and pain
A nurse is caring for a client with a cervical disk herniation. Which of the following clinical manifestations is the client likely to experience?
ANSWER: Paresthesias to the upper extremities. RATIONALE: Cervical disk herniation is typically accompanied by pain, paresthesias, and stiffness
The nurse is caring for a 44-year old indigent male who complains of lower back pain. The physician has ordered a placebo for pain management. Which action by the nurse is appropriate?
ANSWER: Refuse to administer the placebo since they could contribute to mistrust between patients and nurses RATIONALE:Placebos should not be used in clinical practice since it violates the nurse-patient relationship
A client presents to the emergency department with a spinal cord injury. The nurse finds that the client's bowel sounds are absent and the legs are flaccid. These clinical manifestations support which of the following disorders? Answer: Spinal shock RATIONALE: During spinal shock reflex activity stops (bladder and bowel function stop) below the level of the injury and the muscles innervated by the nerve become flaccid and paralyzed
An intensive care nurse receives report on a client in the emergency department who has suffered a C3 spinal cord injury. Which of the following is most important for the nurse to place at the bedside in preparation of the client's arrival? Answer: Ventilator RATIONALE: High cervical injuries (above C4) that injure the phrenic nerve are a leading cause of death from acute respiratory failure
After receiving report on the following clients, the nurse knows that which of the following clients have clinical manifestations that suggest brain death?
Answer: A 20 year old unconscious male with a close head injury who is flaccid and lacks brain stem reflexes. RATIONALE: The three signs of brain death include coma, absence of brain stem reflexes and apnea
A client is admitted for a complaint of lower extremities weakness which has progressively gotten worse over the last 2 months. When assessing the client the nurse observes lower extremity muscle wasting and 4+ patellar reflexes bilaterally. These clinical manifestations are consistent with which disorder?
Answer: Amyotrophic Lateral Sclerosis RATIONALE: Patients with amyotrophic lateral sclerosis present with progressive muscle weakness, atrophy, fatigue hyperactive deep tendon reflexes and spasticity
A nurse observes that a client consistently coughs after swallowing each bite of food. Which of the following actions should the nurse take next?
Answer: Assess cranial nerve X. RATIONALE: Use a tongue depressor to stimulate the gag reflex to assess cranial nerve X
A female client with multiple sclerosis complains of blurry vision. Which of the following actions should the nurse take next?
Answer: Assess visual acuity RATIONALE: Use the Snellen eye chart to assess cranial nerve II and to determine visual disturbances
A client with a brain tumor is receiving dexamethasone (Decadron). The nurse would monitor the client for which of the following clinical manifestations?
Answer: Black tarry stools RATIONALE: Corticosteroid use could result in gastrointestinal hemorrhage
A nurse is caring for a client with a closed head injury and receives a call from the laboratory. The lab reports a sodium value of 120mEq/L. The nurse should evaluate the client for which of the following clinical manifestations?
Answer: Changes in the level of consciousness RATIONALE: Clinical manifestations of hyponatremia consist of headaches, seizures, lethargy, tachycardia, decrease in blood pressure, thready pulse, hyperactive bowel sounds and abdominal cramps
A client with a spinal cord injury at T4 is experiencing facial diaphoresis and has a pounding headache. His pulse is 50 and BP is 210/110 mmHg. Which of the following actions should the nurse take next?
Answer: Check for constipation, urine retention or uncontrolled pain. RATIONALE: Treat autonomic dysreflexia (AD) by placing the patient in an upright position, identifying and relieving the noxious stimulus (insert a foley, manual disimpaction, remove painful stimulus), administering hydralazine and educating the patient about the risk for AD for years after the injury above T6
Upon evaluating a client with a traumatic brain injury the nurse notes the absence of a gag reflex. Which of the following goals of care is the nurse's first priority?
Answer: Decrease the risk of aspiration. RATIONALE: An impaired gag reflex increases the risk for aspiration
A client with a brain tumor is receiving dexamethasone (decadron). The nurse should monitor the client for which of the following clinical manifestations?
Answer: Edema RATIONALE: Corticosteroid use could result in hyperglycemia, sodium retention, weight gain and hypertension
When caring for a client who sustained a lower motor neuron injury and is paralyzed from the waist down, the nurse anticipates which of the following findings?
Answer: Flaccid paralysis RATIONALE: With lower motor neuron injury (spinal cord injury), flaccid paralysis and atrophy occur, whereby with upper motor neuron injury (Stroke), stiffness, spasms and little to no muscle atrophy is observed
Which of the following assessments is the best way to detect early signs of increased intracranial pressure in a client with a traumatic brain injury?
Answer: Glascow coma scale RATIONALE: Use the Glascow Coma Scale (to assess changes in LOC) to rapidly identify early signs of increased intracranial pressure since the level of consciousness (LOC) will change before changes in vital or neurological signs
A nurse is preparing to complete the discharge teaching for a client with a spinal cord injury. Which of the following clinical manifestations should the nurse educate the client about when discussing reasons to seek emergent medical care?
Answer: Headache and profuse facial diaphoresis RATIONALE: Signs of autonomic dysreflexia include extreme hypertension, headache, diaphoresis above the lesion, nasal congestion and bradycardia and results from a noxious stimuli (full bladder, rectum or pain) following the resolution of spinal shock
A nurse is caring for a client with an acute spinal cord injury. The unlicensed assistive personnel reports that the client is unresponsive. Which of the following clinical manifestations suggests that the client is experiencing neurogenic shock?
Answer: Heart rate of 50, blood pressure of 80/40 mmHg and a low cardiac output RATIONALE: Signs of neurogenic shock include bradycardia, decreased blood pressure and cardiac output, peripheral vasodilation and venous pooling
A male client with a history of prostate cancer is admitted for severe, uncontrolled pain in his lumbar back. He denies any recent injury but doesn't want to get out of bed. When reporting these findings to the primary care provider, the nurse would emphasize which finding?
Answer: History of prostate cancer RATIONALE: Pain is a cardinal sign of spinal cord tumors
A nurse is caring for a client with a closed head injury. The client has become increasingly lethargic, complains of a headache, and clears his throat spontaneously. His BP is 120/70, pulse is 80, respirations are 18 and his oxygen saturation is 98%. Which of the following nursing diagnoses is appropriate?
Answer: Ineffective cerebral tissue perfusion related to increased intracranial pressure. RATIONALE: Classic signs of increased intracranial pressure includes restlessness, decreased visual acuity, headache, nausea and vomiting, papilledema, changes in level of consciousness and seizures
The family member of a client who sustained a traumatic brain injury wants to to know what a glascow coma scale score of 8 means. Which of the following is true?
Answer: It indicates a severe head injury. RATIONALE: A glascow comas scale score of 8 or less indicates severe head injury
A client with a history of seizures has suddenly become restless, is more confused and has a respiratory rate of 24. Which of the following actions should the nurse perform next?
Answer: Measure the oxygen saturation. RATIONALE: Signs of hypoxia include restlessness, confusion, pallor, tachycardia and tachypnea
A nurse is caring for a client with Parkinson's disease who takes levodopa routinely. He has a temperature of 103 degrees Fahrenheit, increased muscle rigidity, and a decreased level of consciousness. Which of the following is true? These clinical manifestations are consistent with
Answer: Neuroleptic malignant syndrome. RATIONALE: Neuroleptic malignant syndrome is charecterized by high fever, rigidity and stupor
A client with an intracerebral hemorrhage develops a blood pressure of 190/50 mmHg and pulse of 50. Which of the following actions should the nurse do first?
Answer: Notify the physician of the findings immediately. RATIONALE: Cushing's reflex (widening pulse pressure, bradycardia, hypertension) is a sign of increased intracranial pressure and is triggered by a significant decrease in cerebral perfusion
The nurse is caring for a client with an acute hemorrhagic stroke. Which of the following interventions would be the best option to prevent a venous thromboembolus (VTE)?
Answer: Obtain an order for a pneumatic compression device. RATIONALE: Use pneumatic compression devices to promote venous return and reduce the risk for deep vein thrombosis
An unconscious client with a closed head injury has a dilated left pupil that is slow to respond to light. Which of the following abnormalities best explain the client's clinical manifestations?
Answer: Oculomotor nerve compression RATIONALE: Unilateral pupil dilation and a poor response to light suggests increased pressure to the third cranial nerve whereby bilateral pupil dilation suggests brain stem injury
A client has muscle rigidity with passive range of motion, a tremor that is present at rest and absent while feeding himself, and has slow motor movements. These clinical manifestations are consistent with which disorder?
Answer: Parkinson's Disease RATIONALE: The cardinal signs of Parkinson's is bradykinesia, resting tremors, rigidity and postural instability
The nurse is assessing cranial nerve III. Which of the following responses suggests optimal nerve function?
Answer: Pupils constrict with light RATIONALE: Use a light to stimulate pupil constriction when assessing cranial nerve III
Which of the following nursing interventions is appropriate for the nurse to implement to prevent complications related to immobility in an unconscious client?
Answer: Remove and apply foot splints every two hours. RATIONALE: Use splints to prevent footdrop but remove and reapply every 2 hours
Clients with a closed head injury, a subdural hematoma, an epidural hematoma or a subarachnoid hemorrhage are at an increased risk for which of the following complications?
Answer: Respiratory failure RATIONALE: Conditions that increase intracranial pressure could impair respirations
A client with a traumatic brain injury has a temperature of 102 degrees Fahrenheit. Which of the following is true?
Answer: The temperature may indicate an injury to the hypothalamus. RATIONALE: Hyperthermia increases metabolic demands and could suggest damage to the brain stem in the setting of a head injury
A nurse is caring for a client with a closed head injury who is having difficulty remembering information that was previously learned. The family has been reading about head injuries on the internet and asks the nurse what clients are like after recovery. Which of the following responses is appropriate?
Answer: There could be some difficulty with memory and processing information. RATIONALE:Cognitive impairments following a head injury include memory deficits and difficulty processing information
A nurse is caring for an unconscious client who extends his elbows, pronates his arms, flexes his wrists and points his toes. Which of the following is true?
Answer: This is a poor prognostic indicator. RATIONALE: Joint extension or a lack of motor responses in the setting of a head injury typically suggest a poorer prognosis
A nurse is caring for an unconscious client who extends his elbows, pronates his arms, flexes his wrists and points his toes. Which of the following is true?
Answer: This is a sign of severe neurologic damage. RATIONALE: Abnormal posturing followed by flaccidity in the setting of a cerebral injury is a sign of severe neurologic impairment
A client who is being treated for a cerebral bleed following a head injury becomes agitated. Which of the following interventions is contraindicated for this client? Answer: Applying soft wrist restraints. RATIONALE: Avoid actions that contribute to straining (restraints) in the setting of a head injury because straining increases intracranial pressure
The UAP reports to the nurse that the client seems confused. Which action should the nurse take next? Answer: Ask the client for the current date. RATIONALE: Assess the mental status by observing appearance, dress, posture, facial expressions and noting orientation to person place and time
The nurse is caring for a client who suffered a mild concussion. When assessing the client's cranial nerves III, IV and VI, the nurse should perform which of the following actions? Answer: Perform extraocular eye movements. RATIONALE: Assess cranial nerve III, IV and VI by having the patient follow an object (finger) through all the fields of vision (note nystagmus)
The nurse caring for an unconscious client knows that when performing a neurologic assessment which of the following actions should be included? Answer: Assess corneal reflex RATIONALE: Assess corneal and gag reflex, pupillary response to light, and response to pain when perfoming a neurological assessment
A client is 2 days post cervical discectomy and has only eaten 5-10% of his meals over the last day. Which of the following nursing inteventions would be a priority? Answer: Assist with meal planning and provide preferred food. RATIONALE: Improve appetite by planning meals when the patient is well rested, providing oral hygiene prior to meals, eliminating odors, giving preferred foods, and teaching family not to nag patient about eating
The nurse is caring for a client who has been a paraplegic for 10 years. When creating a treatment plan for the diagnosis of risk for skin impairment, the nurse includes which of the following actions as a priority? Answer: Turn and position every 2 hours RATIONALE: Help to maintain skin integrity by turning and positioning every 2 hours and repositioning every hour when in a chair
The nurse is caring for a client with a closed head injury who has been agitated. The physician has ordered propofol. Which action by the nurse is appropriate? Answer: Administer the medication as ordered. RATIONALE: Propofol (Diprivan) may be used to decrease agitation in the setting of a head injury because it has a rapid onset, is short acting and allows for accurate neurological assessments
The nurse is caring for a client with a traumatic brain injury who is receiving dexamethasone (Decadron). The nurse should monitor for which of the following side effects? Answer: Hyperglycemia RATIONALE: Corticosteroids inhibit the inflammatory response, suppress adrenal gland activity, increase the risk of hyperglycemia and hypernatremia, and hypokalemia, and could mask infection
A client is admitted to the emergency room and diagnosed with a spinal cord injury. Which of the following interventions will prevent a secondary injury? Answer: Maintain the client in a supine position. RATIONALE : Keep patients in an extended, flat position following a spinal cord injury
The unlicensed assistive personnel (UAP) reports to the nurse that the client is coughing when he eats. Which action would the nurse take next? Answer: Test cranial nerve IX and X. RATIONALE: Instruct the patient to swallow to assess cranial nerve IX
A client is 72 hours post traumatic brain injury and has an absent gag reflex. The last bowel movement was today. Which of the following methods is the best way to meet the client's nutritional needs? Answer: Maintain the client on enteral feedings via a nasogastric RATIONALE: Provide enteral feedings in the setting of a head injury with an absent gag reflex
The unlicensed assistive personnel reports to the nurse that the client seems confused. Which of the following assessment techniques should the nurse perform next? Answer: Serial 7s RATIONALE: Perform the serial 7's to assess cognitive function and damage to the frontal cortex
The nurse is caring for a client who had a high spinal cord injury. Which of the following actions best helps to prevent a secondary injury to the cord? Answer: Ensure optimal oxygenation RATIONALE: Maintain a high partial pressure of arterial oxygen following a spinal cord injury to prevent a secondary injury (ischemia and hypoxia) to the cord
Which of the following is an appropriate intervention for the nurse to implement when caring for a client who has had a cervical discectomy? Answer: Teach the patient to turn with the body instead of the neck. RATIONALE: Keep the neck in a neutral position following a cervical diskectomy