SAUNDERS TEST 6/AMS/Davis/Lippincott

Several clients have come to the emergency department after a possible bioterrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply. 1. Violent vomiting. 2. Severe diarrhea. 3. Abdominal pain. 4. Sensory neuropathy. 5. Persistent cough.

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116. When assessing the client with a cord tran. Section above T5 for possible complications, whic, of the following should the nurse expect as least likely to occur? 1. Diarrhea. 2. Paralytic ileus. 3. Stress ulcers. 4. Intra-abdominal bleeding.

1

117. The nurse is planning to teach the client with spinal cord injury and intermittent nasogastric suctioning about interventions to protect the integu- mentary system. The nurse should tell the client to: 1. Eat enough calories to maintain desired weight 2. Stay in cool environments to avoid sweating 3. Stay in warm environments to avoid chilling 4. Eat low-sodium foods to avoid edema.

1

1341. A pediatric client with a spinal cord injury undergoes range of motion exercises several times each day. In teaching the parent how to do range of motion at home, the nurse observes the client increasing the an- gle between the extremity and the midline. The nurse concludes that the client is safely performing: T.Abduction. 2. adduction. 3. flexion. 4, extension.

1

21. Thirty-two children are brought to the emer- gency department after a school bus accident. Two children were killed along with the three people in the car that caused the crash. Before the victims arrive, in addition to ensuring that the hospital stat the prepared for the emergency, which step should the nurse anticipate carrying out? 1. Calling the nearest crisis response team. 2. Alerting the news media. 3. Notifying the hospital volunteer office. 4. Calling the school to inform tachers of the accident.

1

An 11-year-old child is hospitalized for elec- tive surgery. The child has a neurogenic bladder from a spinal cord injury with a lower motor neuron lesion occurring 2 years previously. In planning care, the nurse considers that the optimal treatment for neurogenic bladder in the hospitalized child is: (intermittent catheterization. 2. insertion of a retention catheter. 3. insertion of a suprapubic catheter. 4. administration of an anticholinergic medication.

1

20. A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first aid for this victim include? Select all that apply. 1. Establish an airway with the jaw-thrust maneuver. * 2. Immobilize the spine. 3. Logroll the victim to a side-lying position. 4. Elevate the feet 6 inches (15.2 cm). 5. Place a cervical collar around the neck.

12

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. 1. Triage priority. 2. Identifying information when possible (such as name, age, and address). 3. Medications and treatments administered. 4. Presence of jewelry. 5. Next of kin.

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15. An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. 1. The victim with chemical spills on both arms. 2. The victim with third-degree burns of both legs. 3. The victim with first-degree burns of both hands. 4. The victim in respiratory distress. 5. The victim who inhaled smoke.

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A nurse is caring for a client with a spinal cord injury at the level of the sixth cervical vertebra. The client is at risk for the complication of autonomic dysreflexia. For which associated symptoms should a nurse monitor the client? SELECT ALL THAT APPLY. 1. Sweating 2.Headache 3. Hypotension 4. Blurred vision 5. Anxiety 6. Tachycardia

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38. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the dients 2. Specific requests from the staff 3.The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

15

115. When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? 1. Renal status. 2. Vascular status, 3. Gastrointestinal function. 4. Biliary function.

2

122. As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability? 1. "I won't be able to have sexual intercourse until the urinary catheter is removed." 2."I can participate in sexual activity but might not experience orgasm." 3."I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay." 4."I should be able to participate in sexual activity, but I will be infertile."

2

16. An apartment fire spreads to seven apart- ment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? 1. A woman who is 5 months pregnant with no apparent injuries. 2. A middle-aged man with no injuries who has rapid respirations and coughs. 3. A 10-year-old with a simple fracture of the humerus who is in severe pain. 4. A 20-year-old with first-degree burns on her hands and forearms.

2

19. A car accident involves four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be trans- ported by helicopter to the nearest hospital? 1. A 10-year-old with a simple fracture of the femur who is crying and cannot find his parents. 2. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious. 3. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing. 4.A 70-year-old man with a severe headache who is conscious.

2

837. A nurse in an emergency department assesses a client injured in a diving accident 2 hours earlier. A com- puted tomography (CT) scan reveals a fracture of the C4 cervical vertebra. The client is breathing inde- pendently but has no movement or muscle tone from below the area of injury. The nurse understands that the client: 1. has suffered a complete spinal cord injury (SCI). 2) is experiencing spinal shock. 3. has sustained an upper motor neuron injury. 4. will be a quadriplegic.

2

121. The client with a spinal cord injury ass the nurse why the dietitian has recommended decrease the total daily intake of calcium. Which of the following responsos by the nurse would provide the most accurate information? 1.Excessive intake of dairy products makes constipation more common. 2. "Immobility increases calcium absorption from the intestine." 3. Lack of weight bearing causes demineralization of the long bones 4. 'Dairy products likely; will contribute ° weight gain."

4

17. There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply. 1. Cut around blood stains to remove clothing. 2. Place each item of clothing in a separate paper bag. 3. Hang wet clothing to dry. 4. Refrain from documenting client statements. 5. Place bullets in a sterile container.

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36. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to dient rooms. 2. Move beds away from windows. 3. Close window shades and curtains, 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory dients from the hallways back into their rooms.

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124. Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. 1. Back at the level of the client's scapula. 2. Back and head that are high. 3. Seat that is lower than normal. 4. Seat with firm cushions. 5. Chair controlled by the client's breath.

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112. When planning to move a person with a pos- sible spinal cord injury, the nurse should direct the team to: 1. Limit movement of the arms by wrapping them next to the body. 2. Move the person gently to help reduce pain. 3. Immobilize the head and neck to prevent further injury. 4. Cushion the back with pillows to ensure comfort.

3

113. The nurse is caring for a client with a spi- nal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first? 1. Position the client on the left side. 2. Control the environment by turning the lights off and decreasing stimulation for the client. 3. Check the client's bladder for distention. 4. Administer pain medications.

3

114. The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which of the following findings is expected when assessing this client? 1. Inability to move his arms. 2. Loss of sensation in his hands and fingers. 3. Dysfunction of bowel and bladder. 4. Difficulty breathing.

3

119. During the period of spinal shock, the mus, should expect the client's bladder function to be which of the following? 1. Spastic. 2. Normal. 3. Atonic. 4. Uncontrolled.

3

123. A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which of the following responses by the nurse conveys the best understanding of the client's behavior 1. "Be patient. It takes time to adjust to such a massive loss." 2. "Talking about the past is a form of denial. We have to help you focus on today. 3. "Reviewing your losses is a way to help you work through your grief and loss. 4. "It's a simple escape mechanism to go back and live again in happier times."

3

1338. A teen is brought to an emergency department with a likely spinal cord injury. To minimize the damage from the spinal cord injury, which classification of medications should a nurse expect a health-care provider to prescribe? 1. An antibiotic 2. An analgesic 3. A steroid medication 4. An antihypertensive medication

3

339. An adolescent client diagnosed with a T12 spinal cord injury (SC is admitted to a rehabilitation unit. A nurse is teaching the client about the need to be diligent in skin protection. The nurse explains that the primary reason for the client's increased risk for alterations in skin integrity is: 1. the inability to perceive extremes in temperature leading to burns. 2. the circulatory changes that cause vasoconstriction and decreased blood supply. 3. the inability to feel skin irritation such as wrinkled clothing. 4. the increased likelihood of bowel and bladder dysfunction and skin irritation.

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35. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A dient requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids

3

22. The nurse in the emergency department is triaging the following victims of an airplane cras Phontize the clients in the order in which they should be treated. 1. A 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm. 2. A 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused. 3. A 14-year-old with a 2-inch (5.1-cm) laceration to chin, history of asthma, respirations 26, audible wheezing. 4. A 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes.

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111. A client is being admitted with a spinal cord transection at C7. Which of the following assess- ments take priority upon the client's arrival? Select all that apply. 1. Reflexes. 2. Bladder function. 3. Blood pressure. 4. Temperature. 5. Respirations.

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118. Which of the following should the nurse use's the best method to assess for the development of deep join thrombosis in a client with a spinal cord injus 1. Homans' sign. 2. Pain. 3. Tenderness. 4. Leg girth

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120. After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which of the following responses br the nurse would be the most accurate? 1."These movements indicate that the damaged nerves are healing." 2."This is a good sign. Keep trying to move all the affected muscles." 3."The return of movement means that eventually you should be able to walk again. 4. "The movements occur from muscle reflexes that can't be initiated or controlled by the brain."

4

14. Thirty people are injured in a train derail- ment. Which client should be transported to the hospital first? 1. A 20-year-old who is unresponsive and has a high injury to his spinal cord. 2. An 80-year-old who has a compound fracture of the arm. 3. A 10-year-old with a laceration on his leg. 4. A 25-year-old with a sucking chest

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31. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of dients. 2. A staff member is assigned to determine the dients needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for pro- Viding care to a group of © clients with the aid of an assistive personnel (AP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

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32. The nurse has received the assignment for the day shift After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opiid pain medication 3. A diet scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm' (14 ×10°/L) and a temperature of 38.4° C

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33. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's 1oom and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the AP to find out when the last pain medication was given to the client. 3. Ask the AP to tell the client in pain that medica- lion will be administered as soon as the bed bath is complete. 4. Cover the client, mise the side rails, tell the ciem hat you will return shortly, and administer the pain medication to the other client.

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The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four dients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assigned to the licensed practical nurse? 1. A client who requires a bed bath 2. An older dient requiring frequent ambulation 3. A client who requires hourly vital sign mea- surements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

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The nurse employed in an emergency department is assigned to triage clients coming to the emergcy department for treatment on the evening shift. The nurse should assign priority to which dient? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4

The nurse is assigned to care for four dients. In planning dient rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest ×-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive person- nel (AP) is resistant to the change and is not tak- ing an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance. 2. Exert coercion on the AP. 3. Provide a positive reward system for the AP. 4. Confront the AP to encourage verbalization of feelings regarding the change.

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1. A nurse is planning care for a client who has a spinal cord injury (SC1) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures 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

5. 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. Credé's method D. Indwelling urinary cathete

A

2. 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 blood pressure 220/110 mm Hg and apical heart rate 54/min. 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

3. 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

4. A nurse is caring for a client who experienced a cervical spine injury 24 hr 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