Neuro 2
IVPB prescribed at as 125mg/100mL to infuse over 30 minutes. Drop factor is 10gtts/mL. How many drops per minute (gtts/min) should the RN regulate the IVPB?
33 100x10=1,000 1,000 divided by 30min = 33.3
A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. why is it important that the nurse provide this instruction? A. they usually will never walk b. it prepares them for wearing braces c. it assists them in overcoming orthostatic hypotension d. they have the strength in the upper extremities for self-transfer
A
A pt. has just undergone spinal fusion surgery and returned from the operating room 12 hours ago. which task is best to delegate to the unlicensed assistive personnel? A. log roll the pt. every 2 hours b. help the pt. dangle the legs on the evening of surgery c. assist the pt. to put on a brace so he can get out of bed d. help the pt. ambulate to the bathroom as needed
A
After a client is treated for a spinal cord injury, the health care provider informs the family that the client is a paraplegic. the family asks the nurse what this means. what explanation should the nurse provide? a. lower extremities are paralyzed b. upper extremities are paralyzed c. one side of the body is paralyzed d. both lower and upper extremities are paralyzed
A
After suffering an SCI, a pt. develops autonomic dysfunction, including a neurogenic bladder. what is the priority pt. problem for this condition? a. risk for urinary tract infection b. risk for dehydration c. risk for urinary retention d. risk for urinary incontinence
A
Because the pt. is at risk for spinal shock, what does the nurse monitor for? a. decreased BP, bradycardia, and decreased bowel sounds b. tachycardia and a change in the level of consciousness c. decreased RR and loss of sensation to pain and touch d. paralytic ileus and loss of bowel and bladder function
A
Jonathan is worried about working after his accident. which action should the RN implement? a. refer jonathan to a local counselor for vocational rehabilitation b. discuss the americans with disabilities act with jonathan and his mother c. suggest that jonathan apply for disability payments and not worry about working d. reassure jonathan that everything will be all right after he goes home
A
The nurse review the discharge and home care instructions with a pt. who had back surgery. which statement by the pt. indicates further teaching is needed? a. I will drive myself to my doctors office next week b. I will put a piece of plywood under my mattress c. I will try to increase fruits and vegetables and decrease fat intake d. I plan to get a new ergonomic chair at work
A
What does the nurse do for a client with a cervical laminectomy that differs from then nursing care for a client with a lumbar laminectomy? a. assist with the removal or oral secretions b. maintain the client's head in a flexed position c. elevate the head of the clients bed to a 45 degree angle d. provide range of motion exercise early during the postoperative care
A
What should the nurse assess for when a client with a cervical injury reports a severe headache and nasal congestion? a. suprapubic distention b. increased spinal reflexes c. adventitious breath sounds d. imminent development of shock
A
You are preparing to discharge a client with chronic low back pain. which statement by the client indicates the need for additional teaching? a. I will avoid exercise because the pain gets worse b. I will use heat or ice to help control the pain c. I will not wear high heeled shoes at home or work d. I will purchase a firm mattress to replace my old one
A
a client with a spinal cord injury has paraplegia. the nurse assesses for which major problem the client may experience early in the recovery period? a.bladder control b. nutritional intake c. quadriceps setting d. use of aids for ambulation
A
a nurse finds a victim under the wreckage of a collapsed building. the individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. which action should the nurse take first? A. leave the individual lying on the back with instructions not to move, and seek additional help. b. roll the individual onto the abdomen, place a pad under the head, and cover with any material available. c. gently raise the individual to a sitting position to see whether the pain either diminishes or increases in intensity d. gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution
A
which behavior by the UAP warrants immediate intervention by the RN? a. the UAP is feeding the client b. the UAP is taking a tympanic temperature c. the UAP is emptying the Foley catheter d. The UAP is placing socks on the client's feet
A
which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? a. pain radiating to the hip and leg b. bowel and bladder incontinence c. paralysis of both lower extremities d. overgrowth of tissue on the lower back
A
which intervention should the RN implement to address disuse syndrome? a. perform passive ROM exercises every 4 hours b. encourage Jonathan to avoid stretching his Achilles tendon c. discuss methods to promote regular mental stimulation d. assess the skin for any reddened areas at least every shift
A
which neurologic assessment technique does the nurse use to test a pt. for sensory function? a. touch the skin with a clean paper clip and ask whether it is sharp or dull sensation b. ask the pt. to elevate both arms off the bed and extend wrists and fingers c. have the pt. close the eyes and move the toes up or down; the pt. identifies the positions d. have the pt. sit with the legs dangling; use a reflex hammer to test reflex responses
A
a nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? (SATA) a. coughing or sneezing b. sitting on cold surfaces c. standing for extended periods d. lying supine while flexing the knees e. straining when having a bowel movement
A.E
which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs? a. do not remove the traction weights and ensure they hang freely b. ensure than an extra set of drill bits are available in case a new set of predrilled holes must be made in Jonathan's skull c. place the Velcro binders securely around Jonathan's head d. apply a halo vest when Jonathan is in the upright position
A
which position is therapeutic and comfortable for a patient with lower back pain? a. semi-fowlers position with a pillow under the knees to keep them flexed b. supine position with arms and legs in a correct anatomical position c. orthopneic position; sitting with trunk slightly forward; arms supported on a pillow d. modified Sims position with upper arm and leg supported by pillows
A
Which symptoms indicate that a pt. with a spinal cord injury is experiencing autonomic dysreflexia? (SATA) A. flaccid paralysis b. hypertension c. hypotension d. severe headache e. blurred vision f. loss of reflexes below the injury
B.D.E
what key points does the nurse include in teaching an SCI pt. about bowel and bladder retraining? (SATA) a. ensure the pt. gets a sufficient quantity of fluid each day. b. instruct the pt. about the purpose of stool softeners c. teach the pt. about high fiber foods d. teach the pt. that continence is dependent upon spinal cord healing e. digital rectal stimulation is essential for regular bowel movements
A.B.C
which interventions should the RN implement to address this concern? (SATA) a. allow jonathan to watch TV as much as he likes b. encourage jonathan's girlfriend to talk with him during visits c. provide jonathan prism glasses, and tell him how to use them d. discuss ways for jonathan to deal with his depression e. restrict visitors to immediate family only
A.B.C
A pt. has just undergone a spinal fusion and laminectomy and has returned from the operating room. which assessments are done in the first 24 hours? (SATA) a. take vital signs every 4 hours and assess for fever and hypotension b. perform a neurologic assessment every 4 hours with attention to movement and sensation c. monitor intake and output and assess for urinary retention d. assess for ability and independence in ambulating and moving in bed e. observe for clear fluid on or around the dressing
A.B.C.E
A pt. is scheduled for lumbar surgery. which key points must the nurse include in a preoperative teaching plan for this patient? (SATA) A. techniques for getting in and out of bed b. expectations for turning and moving in bed c. limitations and restrictions for home activities d. restriction of bedrest for at least 48 hours e. report any numbness and tingling to the nurse immediately
A.B.C.E
Which statements about spinal shock are accurate? (SATA) a. it lasts for from less than 48 hours up to a few weeks b. there is temporary loss of motor and sensory function. c. there is permanent loss of motor and sensory function d. there is temporary loss of reflex and autonomic function e. there is permanent loss of reflex and autonomic function
A.B.D
You are helping a client with an SCI to establish a bladder retraining program. which strategies may stimulate the client to void? (SATA) a. stroking the clients inner thigh b. pulling on the clients pubic hair c. initiating intermittent straight catheterization d. pouring warm water over the client's perineum e. tapping the bladder to stimulate the detrusor muscle
A.B.D.E
a client with a cervical SCI has been placed in a fixed skeletal traction with a halo fixation device. when caring for this client, the nurse may delegate which actions to an LPN/LVN? (SATA) a. checking the client's skin for pressure from the device b. assessing the client's neurologic status fro changes c. observing the halo insertion sites for signs of infection d. cleaning the halo insertion sites with hydrogen peroxide e. developing the nursing plan of care for the client
A.C.D
which assessment data warrants immediate intervention by the ED RN? (SATA) a. Jonathan complains of a loss of sensation below his shoulders. his skin is flushed and cool to touch b. Jonathan has a slight sensation in his right metatarsals c. Jonathan's respirations are 20 and unlabored d. Jonathan's BP is 88/48 and his pulse is 50 e. Jonathan appears to have bladder distention
A.D.E
the nurse is caring for a pt. who has been in a long term care facility for several months following and SCI. the pt. has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. which are expected outcomes of the training program? (SATA) a. demonstrates a predictable pattern of voiding b. is able to independently catheterize himself c. pours warm water over perineum to stimulate voiding d. takes bethanechol chloride 1 hour before voiding e. is able to empty the bladder completely f. does not experience a urinary tract infection
A.E.F
A client with a spinal cord injury reports sudden severe throbbing headache that started a short time ago. assessment of the client reveals increased blood pressure (168/94) and decreased heart rate (48bpm), diaphoresis, and flushing of the face and neck. what action should you take first? a. administer the ordered acetaminophen b. check the foley tubing for kinks or obstructions c. adjust the temperature in the clients room d. notify the physician about the change in status
B
A pt. involved in a high speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the emergency room by ambulance with immobilization devices in place. there is a high probability of cervical spine fracture. the patient has altered mental status and extremities are flaccid. what is the priority assessment for this pt.? a. check the mental status using the Glasgow coma scale b. assess the respiratory pattern and ensure a patent airway c. observe for intraabdominal bleeding and hemorrhage d. assess for loss of motor function and sensation
B
Assessment of a pt. with a lower spinal cord injury confirms that the pt. has paralysis of the bilateral lower extremities. how does the nurse document this finding? a. paraparesis b. paraplegia c. quadriparesis d.quadriplegia
B
During the night shift Jonathan has a pounding headache and asks for something. which intervention should the RN implement first? a. assess Jonathan's bladder for distention b. move Jonathan to a sitting position c. administer a ganglionic blocking agent IVP D. attempt to determine what triggered the headache
B
How is jonathan doing? will he ever walk again? what is the best response by the RN? a. he is doing better, but he will never be able to walk again b. I am sorry but I cannot share that information with you c. jonathan is in his room, but I don't think you should visit him d. I think his mother is in the waiting room. let me ask her if I can speak with you about Jonathan
B
If respiratory compromise occurs, what action should the RN take to keep the airway open without compromising Jonathan's spine further? a. logroll to side while maintaining neutral alignment b. perform the jaw thrust technique c. flex the neck with a wedge pillow d. use the chin lift/head tilt technique
B
The nurse is caring for several pt. with SCIs. which task is best to delegate to the UAP? a. encourage use of the incentive spirometry; evaluate the pt. ability to use it correctly b. log roll the pt.; maintain proper body alignment and place a bedpan for toileting c. check for skin breakdown under the immobilization devices during bathing d. insert a foley catheter and report the amount and color of the urine
B
The nurse is preparing to physically assess a patients subjective report of paresthesia in the lower extremities. in order to accomplish this assessment, which assessment technique does the nurse use? a. use a Doppler to locate the pedal pulse, the dorsalis pedis pulse, or the popliteal pulse. b. ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball. c. use a reflex hammer to test for deep tendon patellar or Achilles reflexes d. ask the patient to walk across the room and observe his gait and equilibrium
B
The nurse is taking a history on an older adult patient who reports chronic back pain. the nurse seeks to ID factors that are contributing to the pain. Which question is the most useful in eliciting this information? A. Have you had any recent falls or have you been in an accident? B. Do you have a history of osteoarthritis? C. do you have a history of diabetes mellitus? D. are you having pain that radiates down your leg or into the buttocks?
B
The pt. with chronic back pain is receiving ziconotide by intrathecal infusion with a surgically implanted pump. the patient develops hallucinations. what is the nurse's best first action? a. request a psychiatric evaluation b. notify the health care provider c. perform an assessment of level of consciousness d. decrease the does of medication
B
Which area has priority according to Maslow's hierarchy of needs? a. evaluation of jonathan's ability to transfer from bed to chair b. instructions concerning ways to prevent urinary tract infections c. issues addressing jonathans potential for vocational training d. assurance that significant others have resources available, if needed
B
Which intervention will the RN include when discussing ways to prevent muscle spasticity? a. encourage jonathan to use a footboard at all times b. perform stretching exercises five to seven times each day c. instruct jonathan to lay in the prone position 2 hours daily d. take the prescribed antibiotic when the spasms occur
B
Which outcome should the RN use for evaluation of the efficacy of interventions designed for this nursing diagnosis? a. the clients family inspects the skin for reddened areas daily b. the client exhibits no reddened areas or breaks in the skin c. the nursing staff rotates the client's kinetic bed per unit protocol d. the PT performs passive range of motion exercises
B
Which psychosocial intervention by the RN has priority at this time? a. talk to jonathan's mother about his previous coping skills b. let jonathan know that if he wants to talk or has questions, the RN is available to listen c. notify the HCP to obtain a psychiatric consult d. ask jonathan's mother, girlfriend, and grandparents to limit visits because they seem to cause added stress
B
Which statement by Jonathan indicates an understanding of autonomic dysreflexia? a. if I start feeling lightheaded when I get up, I should raise my head more slowly b. I should empty my bladder at least every 2-3 hours c. it is a complication that occurs if my extremities aren't moved every 2 hours d. its an automatic response that occurs whenever I have a bowel movement
B
Which statement by jonathan's mother indicates that she has an understanding of the bladder care plan designed for jonathan? a. I will limit jonathan's fluid intake so the drainage bad won't fill so quickly b. I should remove the condom catheter nightly to clean his penis c. one the condom catheter is applied I do not need to check it d. if the catheter is draining slowly I should immediately catheterize jonathan to empty the bladder
B
You are floated from the ED to the neurologic floor. which action should you delegate to the UAP when providing nursing care for a client with an SCI? a. Assessing the clients respiratory status every 4 hours b. taking the client's vital signs and recording every 4 hours c. monitoring the clients nutritional status, including calorie counts d. instructing the client how to turn, cough, and breathe deeply every 2 hours
B
a client has paraplegia as a result of a motorcycle accident. what is the reason the nursing care plan should include turning the client every 1 to 2 hours? a. maintain comfort b. prevent pressure ulcers c. prevent flexion contractures of the extremities d. improve venous circulation in the lower extremities
B
a pt. has a long history of chronic back pain and has undergone several back surgeries in the past. at this point the surgeon is recommending a surgical procedure for spine stabilization. which procedure does the nurse anticipate this patient will need? A. laparoscopic diskectomy b. spinal fusion c. laminectomy d. traditional diskectomy
B
for which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk? a. cerebral edema b. sensory loss in legs c. spasms of the bladder d. pain referred to the flanks
B
the nurse and the nursing student are working together to bathe and reposition a pt. who is in a halo fixator device. which action by the nursing student causes the supervising nurse to intervene? a. uses the log roll technique to clean the pt. back and buttocks b. turns the pt. by pulling on the top of the halo device c. positions the pt. with the head and neck in alignment d. supports the head and neck area during the repositioning
B
the nurse is assessing a patient who presented to the emergency department reporting acute onset of numbness and tingling in the right leg. how does the nurse document this subjective finding? a. paraparesis b. paresthesia c.ataxia d. quadriparesis
B
the nurse is assessing a pt. with a spinal cord injury and recognizes that the pt. is experiencing autonomic dysreflexia. what is the nurse's first priority action? a. check for bladder distention b. raise the head of the bed c. administer an antihypertensive medication d. notify the primary health care provider
B
A client with quadriplegia is placed on a tilt table daily. each day the angle of the head of the table gradually is increased. what should the nurse identify as its purpose when the client asks the reason for the tilt table? a. facilitates turning b. prevents pressure ulcers c. promotes hyperextension of the spine d. limits loss of calcium from the bones
D
the nurse is preparing a quadriplegic pt. for discharge and has taught the patients spouse to assist the pt. with a quad cough to prevent respiratory complications. which observation indicates that the spouse has understood what has been taught? a. the spouse assists the pt. to the side of the bed to encourage deep breaths b. the spouse places her hands below the patients diaphragm and pushes upward as the pt. exhales c. the spouse places her hands above the pt. diaphragm and pushes upward as the pt. inhales d. the spouse places the pt. in an upright sitting position to encourage deep breaths.
B
what should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy? a. encourage the client to cough b. reposition the client by log rolling c. assess the client for indications of peritonitis d. instruct the client to bend the knees when turning
B
which information should the RN include when discussing a bowel elimination program with Jonathan? a. explain the importance of drinking cold fluids prior to defecation b. plan bowel evacuation at the same time every day c. the importance of turning to his right side d. daily enemas will be needed to help achieve a bowel movement
B
which intervention should the RN implement first? a. assess Jonathan for symptoms of a paralytic ileus b. notify the ED healthcare provider immediately c. assist the HCP in inserting an endotracheal tube d. prepare to administer the vasoconstrictor dopamine
B
A nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities. what should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures? A. deep massage b. active exercise c. use of a tilt board d. proper positioning
D
a client is in the intensive care unit after sustaining a T2 spinal cord injury. which priority interventions should the nurse include in the client's plan of cares? (SATA) a. minimizing environmental stimuli b. assessing for respiratory complications c. monitoring and maintaining blood pressure d. initiating a bowel and bladder training program e. discussing long-term treatment plans with the family
B.C
the nurse is caring for a pt. with a recent spinal cord injury. which intervention does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? (SATA) a. frequently perform passive ROM exercises b. loosen or remove any tight clothing c. monitor stool output and maintain a bowel program d. keep the pt. immobilized with neck or back braces e. monitor urinary output and check for bladder distention
B.C.E
What should Jonathan's friends do while waiting for emergency personnel to arrive? (SATA) A. Help Jonathan move his legs and assist him to sit up. b. place a blanket over jonathan and make sure no one moves him c. attempt to stabilize his neck with any type of soft material d. carefully put Jonathan in the back of a truck with one man holding his neck e. ensure that the scene around Jonathan is safe and that he is not in any immediate danger
B.E
the nurse is giving home care instructions to a pt. who will be discharged with a halo device. what does the nurse instruct the pt. to avoid? (SATA) a. going out in the cold b. swimming or contact sports c. sexual activity d. bathing in the bathtub e. driving
B.E
A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. what is the primary focus of nursing care during this immediate phase? a. inhibiting urinary tract infections b. preventing contractures and atrophy c. avoiding flexion or hyperextension of the spine d. preparing the client for vocational rehabilitation
C
How should the RN respond to this statement? a. jonathan is a fine young man. he did not do anything wrong. this was just an accident b. just because he does not believe in your way does not mean he is being punished c. sit quietly and allow the grandfather to continue d. request that the grandfather wait a minute and ask an HCP to join the meeting
C
Jonathan is afraid his girlfriend will leave him. Which intervention should the RN implement first? A. encourage Jonathan to talk to his girlfriend about his concerns b. refer jonathan and his GF to a counselor for sexual education c. ask jonathan if he would like to share his fears about life after leaving the hospital d. request a meeting with jonathan's healthcare team
C
Jonathan's mother is sitting and crying. which action by the RN should be implemented at this time? a. allow jonathan's mother to cry and do not disturb her b. ask the hospital chaplain to come and see jonathan's mother c. sit down beside jonathan's mother d. discuss the situation with jonathan as soon as possible
C
The pt. is an adolescent who is quadriplegic as a result of a diving accident. the nursing assistant reports that the pt. started yelling and spitting at her while she was trying to bathe him. he is angry and hostile, stating "nobody is going to do anything else to me! I'm going to get out of this place!" what is the priority pt. problem? a. noncompliance b. cognitive limitations c. inability to cope with the situation d. feelings of hopelessness
C
Which intervention has the highest priority when Jonathan is assessed? a. palpate the lower abdomen for any signs of urinary retention b. assess sensation by gently pinching the skin distal to proximal c. assess Jonathan's breathing pattern and his ability to cough d. monitor the client's vital signs, especially a tympanic temperature
C
Which nursing diagnosis has priority as this time? a. self care deficit b. disturbed sensory perception c. risk for impaired skin integrity d. risk for ineffective coping
C
Which task should the RN delegate to the UAP? a. teach Jonathan how to use the electric wheelchair b. assess Jonathan's ability to perform ADL's c. measure the intake and output for the client taking diuretics d. discuss appropriate ways to prevent urinary tract infections
C
according to the ethical principle of veracity, how should the RN respond to Jonathan's question? a. are you afraid that you may not be able to walk again? b. I always believe in hope, Jonathan, so you shouldn't give up c. no, Jonathan; it is unlikely that you will ever be able to walk again d. I don't think this is a good time to talk about this. you need to sleep
C
after a traumatic spinal cord severance, a young client is having difficulty accepting the paralysis. one day the client has severe leg spasms and says, "my strength is coming back, and I know I will walk again." the nurse's response should be based on what understanding? a. the nerves are regenerating and motor function is returning b. motor function may be returning now that the edema is subsiding c. spinal shock has subsided and the client's reflexes are hyperactive d. the client has developed thrombophlebitis and is experiencing pain.
C
someone said I should have a living will, can you tell me what that is? How should the RN respond? a. you want to know about a living will? are you thinking about hurting yourself? b. I will call the chaplain so he can discuss the living will with you c. it is a legal document that helps us make decisions about your healthcare based on your wishes d. you must appoint someone to make decisions about your treatment if you are unable to do so.
C
the nurse is caring for a pt. with a spinal cord injury who is experiencing neurogenic shock. the pt. systolic BP is 88mm/hg despite starting a dopamine drip 2 hours earlier. there is a new order to infuse 500 mL of dextran-40 over 4 hours. at what rate does the nurse set the infusion pump? a. 75ml/hr b. 100 ml/hr c. 125ml/hr d. 150ml/hr
C
the pt. with a spinal cord injury has a heart rate of 42bpm. which drug does the nurse expect to administer? A. methylprednisolone b. dextran c. atropine d. dopamine
C
what is a potential adverse outcome of autonomic dysreflexia in a pt. with a spinal cord injury? a. heatstroke b. paralytic ileus c. hypertensive stroke d. aspiration and pneumonia
C
which interventions should be implemented for a paralytic ileus? a. encourage jonathan to eat a high calorie, high fiber diet b. turn jonathan every 2 hours in a kinetic bed c. insert a nasogastric tube and set the siphon drainage to a low intermittent suction d. continue to assess Jonathan but take no action at this time
C
which member of the rehabilitation multidisciplinary team is responsible for ensuring that jonathan will be discharged to a home that is equipped to care for him? a. the recreational therapist b. the physiatrist c. the occupational therapist d. the cognitive therapist
C
you are preparing a nursing care plan for a client with an SCI for whom the nursing diagnosis of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. the client tells you, "I don't know why we're doing all this. my life's over." Based on this statement, which additional nursing diagnosis takes priority? a. risk for injury related to altered mobility b. imbalanced nutrition; less than body requirements c. impaired individual resilience related to spinal cord injury d. disturbed body image related to immobilization
C
Which medications should the ED RN expect the HCP to prescribe for Jonathan? (SATA) a. morphine b. mannitol c. methylprednisolone sodium succinate d. dopamine e. acetylsalicylic acid
C.D
A pt. has just undergone a laminectomy and returned from surgery at 1300 hours. at 1530 hours, the nurse is performing the change of shift assessment. which postoperative findings are reported to the surgeon immediately? (SATA) a. minimal serosanguineous drainage in the surgical drain b. pain at the operative site c. swelling or bulging at the operative site d. reluctance or refusal to cough or deep breathe e. moderate clear drainage on the postoperative dressing
C.E
a client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? (SATA) a. spasticity b. incontinence c. flaccid paralysis d. respiratory failure e. lack of reflexes below the injury
C.E
the nurse is providing discharge teaching for a pt. with a spinal cord injury who will be performing an intermittent self-catheterizations at home. which signs and symptoms will the nurse instruct the pt. to report immediately to the primary health care provider? (SATA) a. dysuria b. retention c. fever d. urgency e. foul smelling urine f. back pain
C.E
A client with an SCI at level C3-4 is being cared for in the emergency department. what is the priority assessment? a. determine the level at which the client has intact sensation b. assess the level at which the client has retained mobility c. check blood pressure and pulse for signs and spinal shock d. monitor respiratory effort and oxygen saturation level
D
A pt. has been talking to his physician about drugs that could potentially be used in the treatment of acute low back pain. which statement by the pt. indicates a need for additional teaching? a. the doctor may prescribe a n antiseizure drug such as oxcarbazipine; therefor I would need to have blood tests to check my sodium level b. the doctor may suggest over the counter ibuprofen; therefore I should watch for and report dark tarry stools c. the doctor may prescribe an oral steroid such as prednisone; this would be short term therapy and the dose would gradually taper off d. the doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it.
D
A pt. with an SCI has paraplegia and paraparesis. the nurse has identified a priority pt. problem of inability to ambulate. the nurse assesses the calf area of both legs for swelling, tenderness, redness, or possible complaints of pain. this assessment is specific to the pt. increased risk for which condition? A. contractures of joints b. bone fractures c. pressure ulcers d. deep vein thrombosis
D
a pt. has had an anterior cervical discectomy with fusion and has returned from the recovery room. what is the priority assessment? a. assess for the gag reflex and ability to swallow own secretions b. check for bleeding and drainages at the incision site c. monitor vital signs and check neurologic status d. assess for patency of airway and respiratory effort.
D
what is the best initial action by the RN? a. explain that the grandfather may visit, but only for 10 minutes during visiting hours b. discuss the grandfather's desire with Jonathan, and if he agrees, then allow it. c. request an immediate multidisciplinary team meeting to discuss this situation d. obtain more information about what the grandfather wants to do.
D
what problem is the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake? a. dehydration b. skin breakdown c. electrolyte imbalances d. urinary tract infections
D
which intervention should the RN implement? a. reassure Jonathan that everything will be all right and encourage him no to think like that b. encourage Jonathan to talk to the chaplain about his feelings as soon as possible c. request the hospital ethics committee to meet and discuss Jonathan's wishes d. arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns
D