Unit 6 NUR 213 Practice Questions

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B) "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C) "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D) "The sudden, severe headache increases muscle tone and can cause further nerve damage."

A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

A) Absence of reflexes along with flaccid extremities

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen Lioresal B) Dexamethasone Decadron C) Mannitol Osmitrol D) Phenobarbital Luminal

A) Baclofen Lioresal

The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A) Change the patient's position frequently. B) Provide a high-protein diet. C) Provide light massage at least daily. D) Teach the patient deep breathing and coughing exercises.

A) Change the patient's position frequently

A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent

A) Nerve agent Nerve agent exposure results in visual disturbances, nausea and vomiting, forgetfulness, irritability, and impaired judgment. This presentation is not suggestive of vesicants, pulmonary agents, or blood agents.

Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patients clothing and then perform what action? A) Rinse the patient with water. B) Wash the patient with a dilute bleach solution. C) Wash the patient chlorhexidine. D) Rinse the patient with hydrogen peroxide.

A) Rinse the patient with water. The first step in decontamination is removal of the patients clothing and jewelry and then rinsing the patient with water. This is usually followed by a wash with soap and water, not chlorhexidine, bleach, or hydrogen peroxide.

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? a) "Have you experienced any ptosis in the last few weeks?" b) "Have you had difficulty with urination in the last 6 weeks?" c) "Have you experienced any viral infections in the last month?" d) "Have you developed any new allergies in the last year?"

A. "Have you experienced any viral infections in the last month?" An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? a) Muscle weakness and hyporeflexia of the lower extremities b) Ptosis and muscle weakness of upper extremities c) Hyporeflexia and skin rash d) Fever and cough

A. Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? a) Trigeminal neuralgia b) Migraine headache c) Bell's palsy d) Angina pectoris

A. Trigeminal neuralgia Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis . Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion exercises

B) Applying thigh-high elastic stockings

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

B) Bradycardia and hypertension

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A) Risk for impaired skin integrity B) Risk for injury C) Risk for autonomic dysreflexia D) Risk for suffocation

B) Risk for injury

A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this patients care, the nurse should implement what action? A) The patient should be scrubbed with alcohol and iodine. B) The patient should be carefully protected from infection. C) The patients immunization status should be promptly assessed. D) The patients body hair should be removed to prevent secondary contamination.

B) The patient should be carefully protected from infection. Damage to the hematopoietic system following radiation exposure creates a serious risk for infection. There is no need to remove the patients hair and the patients immunization status is not significant. Alcohol and iodine are ineffective against radiation.

An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what other variable? A) The likelihood of a repeat visit to the ED in the next 7 days B) The resources that the patient is likely to require C) The patients or insurers ability to pay for care D) Whether the patient is known to ED staff from previous visits

B) The resources that the patient is likely to require

Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when? A) At the patient's request B) Each morning and evening C) Every 2 hours D) One hour prior to mobility exercises

C) Every 2 hours

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? a) There should not be a problem, since the medication was only delayed by about 2 hours. b) The patient will require a double dose prior to lunch. c) The muscles will become fatigued and the patient will not be able to chew food or swallow pills. d) The patient will go into cardiac arrest.

C. The muscles will become fatigued and the patient will not be able to chew food or swallow pills. Maintenance of stable blood levels of anticholinesterase medications, such as pyridostigmine (Mestinon), is imperative to stabilize muscle strength. Therefore, the anticholinesterase medications must be administered on time. Any delay in administration of medications may exacerbate muscle weakness and make it impossible for the patient to take medications orally.

The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A) Floors must be scrubbed with undiluted bleach. B) Waste must be promptly incinerated. C) The ventilation system should be deactivated. D) Air ducts and vents should be sealed.

D) Air ducts and vents should be sealed. All air ducts and vents must be sealed to prevent spread. Waste is controlled through double-bagging and the use of plastic-lined containers outside of the facility rather than incineration. Bleach would be ineffective against radiation and the ventilation system may or may not be deactivated.

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination.

D) The patient will require full assistance for all aspects of elimination.

A nurse is performing an assessment on a client who is suspected of having MG. The complaint made by the client that reflects a manifestation commonly seen in clients with this disease is a."By the end of the day, my eyelids usually are drooping." b."I have a great deal of difficulty getting up after I rest for a while." c."I perspire more then I ever have in the past." d."When I have a cold, I usually have a strong cough with it."

a."By the end of the day, my eyelids usually are drooping." The primary feature of MG is increasing weakness with sustained muscle contraction. After a period of rest the muscles regain their strength. Muscle weakness is greatest after exertion or at the end of the day. Ocular manifestations are most common, with ptosis or diplopia occurring in a majority of clients.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? a) Numbness b) Diplopia and ptosis c) Loss of proprioception d) Patchy blindness

b) Diplopia and ptosis The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with a. admission and administration of IV corticosteroids. b. an increased dose of anticholinesterase drugs. c. bolus doses of atropine titrated to effect. d. rest and increased sleep.

b. an increased dose of anticholinesterase drugs. With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other options is used to treat a myasthenic crisis.

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should a. attempt to institute bowel-training activities. b. provide the client with small, frequent feedings. c. obtain an order for intermittent catheterization. d. orient the client to his or her surroundings frequently.

b. provide the client with small, frequent feedings. The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness.

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

A) A patient with a blunt chest trauma with some difficulty breathing The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

A) Check the patient's indwelling urinary catheter for kinks to ensure patency.

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved. B) Obtain the player's vital signs, if possible. C) Perform a rapid assessment of the player's range of motion. D) Assess the player's reflexes.

A) Ensure that the player is not moved.

A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A) Hyperstimulation of the nerve endings B) Temporary deactivation of the nerve endings C) Binding of the nerve endings D) Destruction of the nerve endings

A) Hyperstimulation of the nerve endings Nerve agents can be inhaled or absorbed percutaneously or subcutaneously. These agents bond with acetylcholinesterase, so that acetylcholine is not inactivated; the adverse result is continuous stimulation (hyperstimulation) of the nerve endings. Nerve endings are not deactivated, bound, or destroyed.

The ED staff has been notified of the imminent arrival of a patient who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? A) Impaired gas exchange B) Decreased cardiac output C) Chronic pain D) Excess fluid volume

A) Impaired gas exchange Pulmonary agents, such as phosgene and chlorine, destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolarcapillary oxygen transport mechanisms. Capillary leakage results in fluid-filled alveoli and gas exchange ceases to occur. Pain is likely, but is acute rather than chronic. Fluid volume excess is unlikely to be a priority diagnosis and cardiac output will be secondarily affected by the pulmonary effects.

A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased I.C.P

A) Orthostatic hypotension B) Autonomic dysreflexia C) D.V.T

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

A) Perform a rapid physical assessment. Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

The nursing supervisor at the local hospital is advised that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this patient? A) Primary phase B) Secondary phase C) Tertiary phase D) Quaternary phase

A) Primary phase Pulmonary barotraumas, including pulmonary contusions; head injuries, including concussion, other severe brain injuries; tympanic membrane rupture, middle ear injury; abdominal hollow organ perforation; and hemorrhage are all injuries that can occur in the primary phase of a blast. These particular injuries are not characteristic of the subsequent phases.

A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A) Standard precautions B) Airborne precautions C) Droplet precautions D) Contact precautions

A) Standard precautions The patient is not contagious, and anthrax cannot be spread from person to person, so standard precautions are initiated. Airborne, contact, and droplet precautions are not necessary.

A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A) Urinary retention can have serious consequences in patients with spinal cord injuries B) Urinary function is permanently lost following an spinal cord injury. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.

A) Urinary retention can have serious consequences in patients with spinal cord injuries

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use

A) Young age D) Male gender E) Alcohol or drug use

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? a) Lung auscultation and measurement of vital capacity and tidal volume b) Evaluation of pain and discomfort c) Evaluation of nutritional status and metabolic state d) Evaluation for signs and symptoms of increased intracranial pressure (ICP)

A. Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

Which of the following is the first-line therapy for myasthenia gravis (MG)? a) Pyridostigmine bromide (Mestinon) b) Lioresal (Baclofen) c) Azathioprine (Imuran) d) Deltasone (Prednisone)

A. Pyridostigmine bromide (Mestinon) Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? a) Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. b) After administration of the medication, there will be no change in the status of the ptosis or facial weakness. c) Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. d) The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon.

A. Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis

B) Doing the greatest good for the greatest number of people In nondisaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. A first come, first served approach is unethical.

An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital .C) Have hospital staff put on personal protective equipment. D) Place hospital staff on abbreviated shifts of no more than 4 hours.

B) Establish a triage outside the hospital Triage outside the hospital is the most effective means of preventing contamination of the facility itself. None of the other listed actions has the potential to prevent the contamination of the hospital itself.

A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A) Level A B) Level B C) Level C D) Level D

B) Level B Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection. Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical resistant gloves, and boots. Level D is the same as a work uniform.

A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A) Viral agents B) Nerve agents C) Pulmonary agents D) Blood agents

B) Nerve agents Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.

B) Notify the neurosurgeon of the occurrence.

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

B) Prepare for interventions to increase the patient's BP.

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

B) Small bowel Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A) Administer prophylactic antibiotics. B) Survey the victims using a radiation survey meter. C) Irrigate victims open wounds. D) Perform soap and water decontamination.

B) Survey the victims using a radiation survey meter. Each patient arriving at the hospital should first be surveyed with the radiation survey meter for external contamination and then directed toward the decontamination area as needed. This survey should precede decontamination efforts or irrigation of wounds. Antibiotics are not indicated.

A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A) Victims pre-existing medical conditions are exacerbated. B) Victims are thrown by the pressure wave. C) Victims experience burns from the blast. D) Victims suffer injuries caused by debris or shrapnel from the blast.

B) Victims are thrown by the pressure wave. The tertiary phase of the blast injury results from the pressure wave that causes the victims to be thrown, resulting in traumatic injury. None of the other listed events occurs in this specific phase of a blast.

A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A) Apply a dressing saturated with chlorhexidine. B) Wash the bites with soap and water. C) Arrange for the patient to receive a hepatitis B vaccination. D) Assess the patients immunization history.

B) Wash the bites with soap and water.

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? a) "I was taking a bath." b) "I was brushing my teeth." c) "I was sitting at home watching television." d) "I was putting my shoes on."

B. "I was brushing my teeth." Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse? a) "Don't worry; your child will be fine." b) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." c) "Once Guillain-Barré syndrome progresses to the diaphragm there is a significant decrease in surviving." d) "It's too early to give a prognosis."

B. "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." The survival rate of Guillain-Barré syndrome is approximately 90%. The patient may make a full recovery or suffer from some residual deficits. Telling the parents not to worry is dismissing their feelings and not addressing their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.

Which of the following is the priority nursing intervention for a patient in myasthenic crisis? a) Ensuring adequate nutritional support b) Assessing respiratory effort c) Preparing for plasmapheresis d) Administering intravenous immunoglobin (IVIG) per orders

B. Assessing respiratory effort A patient in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? a) Represents building block of nervous system b) Speeds nerve impulse transmission c) Carries message to the next nerve cell d) Acts as chemical messenger

B. Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a) Brudzinski's sign. b) a positive sweat chloride test. c) a positive edrophonium (Tensilon) test. d) Kernig's sign.

B. a positive edrophonium (Tensilon) 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.

After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patients initial symptoms, the care team should anticipate what event? A) A return to full health B) Internal bleeding C) A latent phase D) Massive tissue necrosis

C) A latent phase A latent phase commonly follows the prodromal phase of radiation exposure. The patient is deemed a possible survivor, not a probable survivor, so an immediate return to health is unlikely. However, internal bleeding and massive tissue necrosis would not be expected in a patient categorized as a possible survivor.

While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? A) Deciding when the facility will go from disaster response to daily activities B) Conducting practice drills for the community and facility C) Conducting a critique and debriefing for all involved in the incident D) Replacing the resources in the facility

C) Conducting a critique and debriefing for all involved in the incident A post-incident response includes critiquing and debriefing all parties involved immediately and at later dates. It does not include the decision to go from disaster response to daily activities; it does not include practice drills; and it does not include replacement of resources in the facility.

A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry

C) Giving milk to drink A patient who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the patient is physically stable and it is deemed appropriate by the physician. Syrup of ipecac is no longer used in clinical settings.

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowlers position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

C) Immobilize the patient on a backboard.

There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patients likelihood of survival be characterized? A) Probable B) Possible C) Improbable D) Extended

C) Improbable Patients who experience vomiting, diarrhea, and shock after radiation exposure are categorized as improbable survival, because they are demonstrating symptoms of exposure levels of more than 800 rads of total body-penetrating irradiation.

The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A) Limit the amount of assistance provided with ADLs. B) Collaborate with the physical therapist and immobilize the patient's extremities temporarily. C) Increase the frequency of ROM exercises. D) Educate the patient about the importance of frequent position changes.

C) Increase the frequency of ROM exercises.

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously

C) Ineffective breathing patterns related to weakness of the intercostal muscles

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises as soon as the patient initiates C) Initiating R.O.M exercises as soon as possible after the injury D) Performing range of motion exercises once a day

C) Initiating R.O.M exercises as soon as possible after the injury

A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension? A) Administer an IV bolus of normal saline prior to repositioning. B) Maintain bed rest until normal BP regulation returns. C) Monitor the patient's BP before and during position changes. D) Allow the patient to initiate repositioning.

C) Monitor the patient's BP before and during position changes.

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

C) Perform passive ROM exercises as ordered.

A patient suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurses most appropriate action? A) Place the patient in the Trendelenberg position. B) Assess the patients airway and begin chest compressions. C) Position the patient in the prone, left lateral position. D) Encourage the patient to perform deep breathing and coughing exercises.

C) Position the patient in the prone, left lateral position. In the event of an air embolus, the patient should be placed immediately in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber. Chest compressions, deep breathing, and coughing would exacerbate the patients condition. Trendelenberg positioning is not recommended.

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

C) Spinal shock

A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition? A)Chronic confusion B)Impaired urinary elimination C)Impaired verbal communication D)Bowel incontinence

C)Impaired verbal communication Impaired communication is an appropriate nursing diagnosis; the voice in patients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in patients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? a) Assess the respiratory rate and oxygen saturation. b) Listen to the bowel sounds. c) Assess the blood pressure and heart rate. d) Assess the peripheral pulses.

C. Assess the blood pressure and heart rate. The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction so that interventions can be initiated quickly if needed.

A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status

D) Assessment of respiratory status The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms. The second stage of infection by inhalation does not include headache, vomiting, or syncope.

A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine

D) Atropine Atropine is administered when a patient is exposed to a nerve agent. Exposure to blood agents, such as cyanide, requires treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered IV for systemic toxicity and topically for skin lesions when exposed to vesicants. Erythromycin is an antibiotic, which is ineffective against nerve agents.

A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patients identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patients chart.

D) Clearly document LOC and health status on the patients chart. When patients are unconscious and in critical condition, the condition and situation should be - 1356 documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the patients identity is not a priority. Obtaining a court order would take too long.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury . The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

D) Motor vehicle accidents

A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patients skin will eventually show what manifestation? A) Erythema B) Ecchymosis C) Desquamation D) Necrosis

D) Necrosis Necrosis of the skin will become evident within a few days to months at doses of more than 5,000 rads. With 600 to 1,000 rads, erythema will occur; it can disappear within hours and then reappear. At greater than 1,000 rads, desquamation (radiation dermatitis) of the skin will occur. Ecchymosis does not occur.

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded.

D) The patient's urinary catheter became occluded.

The nurse is preparing to admit patients who have been the victim of a blast injury. The nurse should expect to treat a large number of patients who have experienced what type of injury? A) Chemical burns B) Spinal cord injury C) Meningeal tears D) Tympanic membrane rupture

D) Tympanic membrane rupture Tympanic membrane (TM) rupture is the most frequent injury after subjection to a pressure wave resulting from a blast injury because the TM is the bodys most sensitive organ to pressure. In most cases, other injuries such as meningeal tears, spinal cord injury, and chemical injuries are likely to be less common.

When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Nerve agent B) Blood agent C) Pulmonary agent D) Vesicant

D) Vesicant Sulfur mustard is a vesicant chemical that causes blistering and results in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death. Nerve agents include sarin, soman, tabun, VX, and organophosphates (pesticides). Hydrogen cyanide is a blood agent that has a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. Chlorine is a pulmonary agent, which destroys the pulmonary membrane that separates the alveolus from the capillary bed.

Myasthenia gravis occurs when antibodies attack which receptor sites? a) Dopamine b) Gamma-aminobutyric (GABA) c) Serotonin d) Acetylcholine

D. Acetylcholine In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.

A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged? A) Green B) Yellow C) Red D) Black

D. Black The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The patient would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease? a) Red blood cells present in the CSF b) Glucose in the CSF c) White blood cells in the CSF d) Elevated protein levels in the CSF

D. Elevated protein levels in the CSF Serum laboratory tests are not useful in the diagnosis. However, elevated protein levels are detected in CSF evaluation, without an increase in other cells.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following? a) Blindness b) Bulbar weakness c) Inability to swallow d) Tachycardia

D. Tachycardia Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension.

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? a) Place the patient in the supine position. b) Administer atropine to control the side effects of edrophonium. c) Call the rapid response team because the patient is preparing to arrest. d) Administer diphenhydramine (Benadryl) for the allergic reaction.

b) Administer atropine to control the side effects of edrophonium. Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

Which of the following is the priority nursing intervention for a patient in myasthenic crisis? a) Ensuring adequate nutritional support b) Administering intravenous immunoglobin (IVIG) per orders c) Assessing respiratory effort d) Preparing for plasmapheresis

c) Assessing respiratory effort A patient in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis? a) Hyporeflexia and weakness of the lower extremities b) Ptosis and diplopia c) Facial distortion and pain d) Fatigue and depression

c) Facial distortion and pain Bell's palsy is manifested by facial distortion, increased tearing, and painful sensations in the face, behind the ear, and in the eye. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.

Bell's palsy is a disorder of which cranial nerve? a) Trigeminal (V) b) Vagus (X) c) Vestibulocochlear (VIII) d) Facial (VII)

d) Facial (VII) Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière's syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? a) Suggest applying cool compresses on the face several times a day to tighten the muscles. b) Inform the patient that the muscle function will return as soon as the virus dissipates. c) Tell the patient to smile every 4 hours. d) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

d) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.