2202 chapter 40

A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

A. Purulent drainage from the pin sites on the client's forehead

A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds. B. Manage the client's airway. C. Check oxygen saturation level. D. Perform a neurologic assessment.

B. Manage the client's airway.

Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries? A. "I need to lose weight because I'm too big." B. "I should not stand or sit for a long period of time." C. "It would be best if I could get ergonomic office furniture." D. "Exercise is not going to help my back very much."

D. "Exercise is not going to help my back very much."

A nurse is assessing a client with a suspected diagnosis of multiple sclerosis. Which assessment findings will the nurse expect? Select all the apply. A. Resting tremors B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria

B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria

A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110 mm Hg. What is the nurse's priority action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Place the patient in a sitting position. D. Turn on a fan to cool the patient.

C. Place the patient in a sitting position.

The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug? A. "Report changes in urinary and bowel elimination immediately." B. "Follow up for annual lab testing to monitor for liver toxicity." C. "Rotate the sites for your self-administered injections." D. "Avoid crowded places such as malls and large public gatherings."

D. "Avoid crowded places such as malls and large public gatherings."