Practice Problems unit 4

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take? A. Elevate the head of the bed. B. Examine the rectum digitally. C. Assess the client's blood pressure. D. Place the client in the prone position.

A

The nurse is preparing to assess a motor vehicle accident victim who was lap and shoulder harness restrained. Due to the mechanism of injury the nurse will look for which most common injuries? Select all that apply. a. Lumbar spine fractures b. Fractured patella c. Pulmonary contusion d. Flexion fracture of the cervical spine e. Cardiac contusion

C, E

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse would keep which most important items available at the client's bedside? A. Oxygen and metered-dose inhaler B. Ambu bag and suction equipment C. Pulse oximeter and cardiac monitor D. Incentive spirometer and cough pillow

B

A patient who sustained a chest injury has developed tracheal deviation to the left side. The emergency department nurse would provide which equipment for immediate treatment of this complication? a. Central line insertion tray b. A chest tube c. Endotracheal tube d. 18-gauge needle for intravenous access

B

During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with post-traumatic stress disorder? A. Explaing the unit rules B. making the client feel safe C. oreienting the client to the unit D. stabilizing the client's psychiatric needs

B

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget? A. Escort the client to a private, low-stimulus room. B. Engage the client in a nonthreatening conversation. C. Allow the client to pace unless the behavior becomes aggressive. D. Share the observation with the client so that the behavior can be recognized.

D

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? A. Altered breathing pattern B. Increased likelihood of injury C. Ineffective oxygen consumption D. Increased susceptibility to aspiration

A

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The primary health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? A. Atropine sulfate B. Morphine sulfate C. Protamine sulfate D. Pyridostigmine bromide

A

A client with myasthenia gravis is at highest risk for which complication? a. Aspiration b. Bladder dysfunction c. Hypertension d. Sensory loss

A

The nurse is caring for a client with myasthenia gravis who has received edrophonium by the intravenous route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. Which response would the nurse make to the client? A. "It will last for 4 to 5 minutes." B. "It will last for about 30 minutes." C. "It will last longer than 60 minutes." D. "It will last approximately 10 minutes."

A

The nurse is teaching a client with paraplegia from a spinal cord injury measures to maintain skin integrity. Which instruction will be most helpful to the client? A. Shift weight every 2 hours while in a wheelchair. B. Change bedsheets every other week to maintain cleanliness. C. Place a pillow on the seat of the wheelchair to provide extra comfort. D. Use a mirror to inspect for redness and skin breakdown twice a week.

A

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention would be included in the care plan for this client? Select all that apply. A. Provide oral hygiene after each meal. B. Assess swallowing ability frequently. C. Allow the client sufficient time to eat. D. Maintain a suction machine at the bedside. E. Provide a full liquid diet for ease in swallowing.

A, B, C, D

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. A. Keeping the linens wrinkle-free under the client B. Preventing unnecessary pressure on the lower limbs C. Limiting bladder catheterization to once every 12 hours D. Turning and repositioning the client at least every 2 hours E. Ensuring that the client has a bowel movement at least once a week

A, B, D

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. A. Spontaneous breathing B. Oxygen saturation of 98% C. Adventitious breath sounds D. Normal arterial blood gas levels E. Vital capacity within normal range

A, B, D, E

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? A. Take the temperature. B. Listen to breath sounds. C. Observe for dyskinesias. D. Assess extremity muscle strength.

B

A client develops muscle weakness and seeks attention from a HCP. The client asks the nurse during the initial assessment if the symptoms suggest amyotrophic lateral sclerosis (ALS), Which is the most appropriate response to the client? a. "You may have been working too much and tis why you are tired. Let's not think the worst." b. "Tell me what has you are thinking that you might have ALS?" c. "Have you been having trouble remembering things along with this weakness?" d. "Well, you are in the right place to figure out what is going on!"

B

A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact? A. The client has experienced more than one sexual assault. B. The client routinely incorporates foreign objects into the sex act. C. The client actively and commonly initiates situations in which sex is forced. D. The client regularly reexperiences the events associated with the assault.

D

A client is suspected of having myasthenia gravis. Edrophonium is administered intravenously to determine the diagnosis. Which indicates that the client may have myasthenia gravis? A. Joint pain following administration of the medication B. Feelings of faintness, dizziness, hypotension, and signs of flushing in the client C. A decrease in muscle strength within 30 to 60 seconds following administration of the medication D. An increase in muscle strength within 30 to 60 seconds following administration of the medication

D

The nurse is caring for a client with Guillian-Barre syndrome. Which associated complication should the nurse monitor for in this patient? a. Autonomic dysreflexia b. Septic emboli c. Increased intracranial pressure (IICP) d. Respiratory failure

D

The nurse is caring for client with a T1 spinal cord injury. The nurse checks the client at 4am to assist with a change in position. The client reports a pounding headache. The nurse checks the client's BP and notes that it is 156/100. The nurse should perform these actions in priority order. Place the actions in order from first to last. 1. Notify the HCP 2. Check for fecal impaction 3. Elevate the head of the bed 4. Check the bladder for distension

3, 4, 1, 2

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? A. Bradycardia B. Hyperthermia C. Hypoglycemia D. Increased cardiac output

A

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP would the nurse question? A. Clear liquid diet B. Bilateral calf measure C. Monitor vital signs frequently D. Passive range-of-motion (ROM) exercises

A

The primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication would the nurse expect to be prescribed and administered by this route? A. Baclofen B. Chlorzoxazone C. Dantrolene sodium D. Cyclobenzaprine hydrochloride

A

Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events? a. "I attend my therapy sessions regularly." b. "Those intrusive memories are hidden for a reason and should stay hidden." c. "Keeping busy is the key to getting mentally healthy." d. "I've agreed to move in with my parents so I'll get the support I need."

A

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? A. Bilateral loss of pain and temperature sensation B. Ipsilateral paralysis and loss of touch and vibration C. Contralateral paralysis and loss of touch, pressure, and vibration D. Complete paraplegia or quadriplegia, depending on the level of injury

B Ipsilateral paralysis: motor paralysis on the same (ipsilateral) side as the lesion and deficits in pain and temperature sensation on the opposite side

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. A. "I'm afraid of spiders." B. "I keep reliving the robbery." C. "I see that face everywhere I go." D. "I don't want anything to eat now." E. "I might have died over a few dollars in my pocket." F. "I have to wash my hands over and over again many times."

B, C, E

The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. Evaluation of the results indicates that the test is positive. Which would be the expected response noted by the nurse? A. Joint pain for the next 15 minutes B. An immediate increase in blood pressure C. An increase in muscle strength within 1 to 3 minutes D. Feelings of faintness or dizziness for 5 to 10 minutes

C

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? A. Hyperreflexia B. Positive reflexes C. Flaccid paralysis D. Reflex emptying of the bladder

C

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder? A. "I'm always crying." B. "I'm afraid to go outside." C. "I keep reliving the abuse." D. "I keep washing my hands over and over."

C

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect? A. Return of spinal shock B. Malignant hypertension C. Impending brain attack (stroke) D. Autonomic dysreflexia (hyperreflexia)

D

A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine. The nurse would check to see that the client takes the medication at what time? A. With meals B. Between meals C. Just after meals D. 30 minutes before meals

D

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? A. Keeping the client on a stretcher B. Logrolling the client onto a soft mattress C. Logrolling the client onto a firm mattress D. Placing the client on a bed that provides spinal immobilization

D

The nurse is caring for a client with GBS. When teaching the client and family about the treatment for this syndrome, which information should the nurse include? a. Need for total bed rest. b. Preparation for permanent paralysis c. Use of antibiotics to resolve the syndrome d. Possible treatment with plasmapheresis

D

The nurse is planning care for the patient in the recovery stage of Guillian-Barre syndrome. Which nursing action is the highest priority? a. Provide frequent mouth care b. Perform intermittent catheterization every 4 hours c. Encourage active ROM exercises d. Administer pain medication as needed

D

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the primary health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? A. Multifocal seizures B. Altered level of consciousness C. Abrupt onset of a fever and headache D. Development of progressive muscle weakness

D

The primary health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? Select all that apply. A. Edrophonium is a long-acting cholinesterase inhibitor. B. Atropine is used to reverse the effects of edrophonium. C. If symptoms worsen following administration of edrophonium, the crisis is cholinergic. D. Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. E. An improvement in symptoms following administration of edrophonium indicates myasthenic crisis.

B, C, D, E

The client stabilized and moved to the neurologic intensive care unit with a diagnosis of SCI at level C4 to C5. As the admitting RN working with an experienced unlicensed assistive personnel (UAP), when frequent respiratory assessments are performed, which actions can the RN delegate to the UAP? Select all that apply. a. Auscultating breath sounds every hour to detect decreased or absent ventilation b. Recording accurate intake and output c. Teaching the client to breathe slowly and deeply and use incentive spirometry d. Checking the client's oxygen saturation by pulse oximetry every 2 hours e. Assessing the client's chest wall movement during respirations

B, D

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving client full control over care decisions and restricting visitors B. Providing positive feedback and encouraging active range of motion C. Providing information, giving positive feedback, and encouraging relaxation D. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

C

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? A. Getting too little exercise B. Taking excess medication C. Omitting doses of medication D. Increasing intake of fatty foods

C

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? A. Notify the neurologist. B. Loosen tight clothing on the client. C. Place the client in a sitting position. D. Check the urinary catheter tubing for kinks or obstruction.

C

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? A. "Here's the MedicAlert bracelet I obtained." B. "I need to take my medications an hour before mealtime." C. "Going to the beach will be a nice, relaxing form of activity." D. "I've made arrangements to get a portable resuscitation bag and home suction equipment."

C

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? A. "I will rest each afternoon after my walk." B. "I should cough and deep-breathe many times during the day." C. "I can change the time of my medication on the mornings when I feel strong." D. "If I get abdominal cramps and diarrhea, I should call my health care provider."

C

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing 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 of spinal shock. d. Monitor respiratory effort and oxygen saturation level.

D

A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if in cholinergic crisis? A. No change in the condition B. Complaints of muscle spasms C. An improvement of the weakness D. A temporary worsening of the condition

D

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? A. Meningitis or encephalitis during the last 5 years B. Seizures or trauma to the brain within the last year C. Back injury or trauma to the spinal cord during the last 2 years D. Respiratory or gastrointestinal infection during the previous month

D

The nurse has received the client assignment for the day. Which client would the nurse care for first? A. A client asking to leave against medical advice (AMA) B. A client who is a fall risk and needs assistance to the bathroom C. A client needing medication before breakfast because it is a timed dose D. A client recently admitted after a motor vehicle accident still in cervical spine precautions

D

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room? A. Nebulizer and pulse oximeter B. Blood pressure cuff and flashlight C. Flashlight and incentive spirometer D. Electrocardiographic monitoring electrodes and intubation tray

D