Test 4 nclex style questions
The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? a) The tremors sometimes disappear with purposeful and voluntary movements. b) The tremors disappear when the client's attention is diverted by some activity. c) There is no explanation for the observation; it is a chance occurrence. d) The tremors are probably psychological and can be controlled at will.
A) The tremors sometimes disappear with purposeful and voluntary movements. Explanation: Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.
You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply). A Stroke the patient's inner thigh. B Pull on the patient's pubic hair. C Initiate intermittent straight catheterization. D Pour warm water over the perineum. E Tap the bladder to stimulate detrusor muscle.
A, B, D, E All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI. Intermittent bladder catheterization can be used to empty the patient's bladder, but it will not stimulate voiding. Focus: Prioritization
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.
ANS: D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
19. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion
ANS: A Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to a. suction the patient's oral and pharyngeal airway. b. administer oxygen at 7 to 9 L/min with a face mask. c. place the hands on the epigastric area and push upward when the patient coughs. d. encourage the patient to use an incentive spirometer every 2 hours during the day.
ANS: C Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
A patient with Parkinson's disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene? A The NA assists the patient to ambulate to the bathroom and back to bed. B The NA reminds the patient not to look at his feet when he is walking. C The NA performs the patient's complete bath and oral care. D The NA sets up the patient's tray and encourages patient to feed himself.
C The nursing assistant should assist the patient with morning care as needed, but the goal is to keep this patient as independent and mobile as possible. Assisting the patient to ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to goal of maintaining independence.
A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance? a) Make sure the client is sitting with the head of bed elevated to 90 degrees. b) There are no special precautions for the client with Parkinson's disease. c) Assist the client into a comfortable position and stay alert for coughing, which signifies aspiration. d) Clients with Parkinson's disease shouldn't have liquids; remove them from the dinner tray before serving food to the client.
A) Make sure the client is sitting with the head of bed elevated to 90 degrees. Explanation: Clients with Parkinson's disease are at risk for aspiration; therefore, the nurse should instruct the ancillary staff member to make sure the head of the client's bed is elevated to 90 degrees before assisting the client with eating. A client doesn't always cough when he aspirates. A client with Parkinson's disease needs fluids to maintain fluid balance. Aspiration is a great concern with Parkinson's disease; therefore; the staff should take precautions to prevent this complication.
A client with Parkinson's disease needs a long time to complete morning care, but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? a) Praise the client for the desire to be independent and give extra time and encouragement. b) Tell the client that he or she is being unrealistic about the abilities and must accept the fact that he or she needs help. c) Suggest to the client to at least modify the morning care routine if he or she insists on self-care. d) Tell the client firmly that he or she needs assistance and help with her care.
A) Praise the client for the desire to be independent and give extra time and encouragement. Ongoing self-care is a major focus for clients with Parkinson's disease. The client should be given additional time as needed and praised for efforts to remain independent. Firmly telling the client that he or she needs assistance will undermine self-esteem and defeat efforts to be independent. Telling the client that perception of the situation is unrealistic does not foster hope in the ability to perform self-care measures. Suggesting that the client modify the morning routine seems to put the hospital or the nurse's time schedule before the client's needs. This will only decrease the client's self-esteem and the desire to try to continue self-care, which is obviously important to the client.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a) a positive edrophonium test. b) Kernig's sign. c) a positive sweat chloride test. d) Brudzinski's sign
A) a positive edrophonium test. A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone. Kernig's sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to confirm cystic fibrosis.
The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for: a) sudden, severe hypertension b) paralytic ileus c) bradycardia d) hot, dry skin
A) sudden, severe hypertension With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating. Bradycardia, paralytic ileus, and hot, dry skin typically occur during spinal shock, not during autonomic dysreflexia.
All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson's disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? (Choose all that apply). A Check for orthostatic changes in pulse and blood pressure. B Monitor for improvement in tremor after levodopa (L-dopa) is given. C Remind the patient to allow adequate time for meals. D Monitor for abnormal involuntary jerky movements of extremities. E Assist the patient with prescribed strengthening exercises. F Adapt the patient's preferred activities to his level of function.
A,C,E NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists. Evaluation of patient response to medication and development and individualizing the plan of care require RN-level education and scope of practice. Focus: Delegation
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.
ANS: A Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.
A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best? a. Ask for the patient's input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patient's comments.
ANS: A The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation
ANS: A The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers
ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.
ANS: B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.
ANS: B The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?
ANS: C The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and support the spouse's participation.
ANS: C The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position
ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.
ANS: D The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.
Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent off urine and stool. What is your best first action at this time? A Administer an acetaminophen suppository. B Notify the physician immediately. C Recheck vital signs in 1 hour. D Reschedule patient's physical therapy.
B The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient's respiratory status. The patient may need incubation and mechanical ventilation. The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen. This patient's vital signs need to be re-checked sooner than 1 hour. Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI? A Assess patient's respiratory status every 4 hours. B Take patient's vital signs and record every 4 hours. C Monitor nutritional status including calorie counts. D Have patient turn, cough, and deep breathe every 3 hours.
B The nursing assistant's training and education include taking and recording patient's vital signs. The nursing assistant may assist with turning and repositioning the patient and may remind the patient to cough and deep breathe but does not teach the patient how to perform these actions. Assessing and monitoring patients require additional education and are appropriate to the scope of practice for professional nurses. Focus: Delegation/supervision
The nurse monitors a client who has been diagnosed with brain death and is a potential organ donor. Which client assessment data indicate to the nurse that the standard of care an organ donor has been maintained? a) pH of arterial blood: 7:32 b) urine outputs: 45 mL/hr c) capillary refill: 5 seconds d) blood pressure: 90/48 mm Hg
B - Urine output at 45 mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output.
A client has been hospitalized with a diagnosis of myasthenia gravis. A friend is visiting the client during lunch. The nurse enters the room after the client recovered from choking on lunch. What should the nurse do next? a) Encourage the client to eat alone. b) Tell the client to swallow when her chin is tipped down on her chest. c) Instruct the client to sit at a 30-degree angle in bed when eating. d) Remind the client to rest after eating.
B Tell the client to swallow when her chin is tipped down on her chest. Explanation: Bending the chin down toward the chest decreases the risk of food entering the trachea and causing aspiration into the lungs. The client should sit up at a 90-degree angle when eating. Although eating and talking increase the risk of aspiration as well as muscle fatigue, the nurse should encourage the client to have visitors but avoid talking while chewing and swallowing. The client should rest before eating because muscle fatigue can contribute to choking.
What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving b) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking c) Muscle pain, difficulty speaking, headaches, and arthritic changes d) Muscle inflammation, choking when eating, nearsightedness, and painful joints
B) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking Explanation: With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.
An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element? a) fluids b) sodium c) protein d) potassium
B) sodium Explanation: Ménière's disease is commonly seen in older women; the disorder is caused by pressure within the labyrinth of the inner ear as a result of excess endolympha resulting in swelling in the cochlea. Therefore, the nurse should instruct the client about dietary restrictions of sodium to reduce fluid retention. Pharmacologic treatment includes antivertiginous drugs and diuretics. If the client is prescribed a diuretic, the fluid and electrolytes are monitored. The amount of protein does not have a direct influence in this disease process.
A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Hyperreflexia along with spastic extremities b) Spasticity of all four extremities c) Absence of reflexes along with flaccid extremities d) Positive Babinski's reflex along with spastic extremities
C) Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) increase the dose of muscle relaxants. b) avoid naps during the day. c) rest in an air-conditioned room. d) take a hot bath.
C) rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that: A: Patients must have an organ donor card to donate organs. B:Non-heart beating cadavers are not potential organ donors. C: Hospitals are mandated to notify transplantation programs of potential donors. D: Nursing focus should be directed at organ donation once it is decided to withdraw life support.
C: Hospitals are mandated to notify transplantation programs of potential donors. Rationale: The scarcity of organs has resulted in legislation mandating hospitals and other healthcare agency to notify transplantation program for potential donors. New protocols allow the retrieval of organs from non-heart beating cadavers. The family of the deceased patient may decide not to donate the organs, and a donor card is not necessary in this circumstance. Attention to optimal patient and family care at the time of life-sustaining therapy withdrawal should remain the nurses priority and care.
The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time? A Fatigue related to disease state B Activity Intolerance due to generalized weakness C Impaired Physical Mobility related to neuromuscular impairment D Self-care Deficit related to fatigue and neuromuscular weakness
D At this time, based on the patient's statement, the priority is Self-Care Deficit related to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a patient with MS, but they are not related to the patient's statement. Focus: Prioritization
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment? A Determine the level at which the patient has intact sensation. B Assess the level at which the patient has retained mobility. C Check blood pressure and pulse for signs of spinal shock. D Monitor respiratory effort and oxygen saturation level
D The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 - 5) innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary, but not as high priority. Focus: Prioritization
In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Transfer the patient to radiology for spinal computed tomography (CT). e. Immobilize the patient's head, neck, and spine.
E, C, B, A, D The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A Administer the ordered acetaminophen (Tylenol). B Check the Foley tubing for kinks or obstruction. C Adjust the temperature in the patient's room. D Notify the physician about the change in status
b These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic dysreflexia that is causing the patient's headache. Notification of the physician may be necessary if nursing actions do not resolve symptoms
The client who has been diagnosed with brain death had received vigorous treatment to control cerebral edema. Which intervention does the nurse plan to implement to maintain viability of the kidneys before organ donation? a) screen the donor for infection b) administer intravenous (IV) fluids c) maintain ventilation and oxygenation d) administer vasopressors intravenously
b need to perfuse kidneys!
The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation? a) slurring of words when excited b) visual hallucinations c) inappropriate laughter d) an exaggerated sense of well-being
d) an exaggerated sense of well-being Explanation: A client with multiple sclerosis may have a sense of optimism and euphoria, particularly during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of euphoria