Adult Health 2 Final

A client with a C4 spinal injury would most likely have which of the following symptoms? a.) Aphasia b.) Hemiparesis c.) Paraplegia d.) Tetraplegia

d.) Tetraplegia Rationale: Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.

To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to a. splint the chest when coughing. b. maintain fluid restrictions. c. wear the nasal oxygen cannula. d. try the pursed-lip breathing technique.

A Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange in patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia.

The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant a. turns the patient over to the right side. b. splints the patient's chest during coughing. c. elevates the patient's head to 45 degrees. d. assists the patient to get up to the bathroom.

A Rationale: Positioning the patient with the left (or "good" lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia.

A patient with primary pulmonary hypertension is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the patient reports decreased exertional dyspnea. b. the blood pressure is less than 140/90 mm Hg. c. the heart rate is between 60 and 100 beats/minute. d. the patient's chest x-ray indicates clear lung fields.

A Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

The health care provider writes the following admitting orders for a patient with suspected IE who has fever and chills: ceftriaxone (Rocephin) 1.0 g intravenous piggyback (IVPB) q12hr, acetylsalicylic acid (ASA) for temperature above 102° F (38.9° C), and blood cultures 2, complete blood cell count (CBC), and electrocardiogram (ECG). When admitting the patient, the nurse gives the highest priority to a. obtaining the blood cultures. b. initiating the IV antibiotic. c. scheduling the ECG. d. administering the ASA.

A Rationale: Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The ECG and ASA should also be accomplished rapidly, but the blood cultures (and then administration of the antibiotic) have highest priority.

You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)? A. Eye opening B. Abstract reasoning C. Best verbal response D. Best motor response E. Cranial nerve function

A,C,D The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion- Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for a. patency of of airway b. presence of a neck injury c. neurologic status with Glascow Coma Scale d. CSF leakage from ears and nose

A. Patency of airway is the #1 priority with all head injuries

A patient is seen at the clinic for a routine examination. After the patient is assessed for evidence of peripheral vascular disease (PVD), what does the nurse explain is a commonly used screening tool for poor peripheral circulation to assess PVD? A. ankle-brachial index B. handheld doppler C. peripheral pulse assessment D. angiography

A. ankle-brachial index

A patient with percarditis reports increasing chest pain. The nurse further assesses the patient's pain based on the knowledge that: A. chest pain with pericarditis is expected, but increasing chest pain could indicate other complications, such as a myocardial infacrtion B. chest pain with pericarditis in an uncommon finding and needs to be further assessed C. actually, assessing chest pain is not necessary D. I can't come up with a third option so please pick one of the above

A. chest pain with pericarditis is expected, but increasing chest pain could indicate other complications, such as a myocardial infarction. It is important to distinguish between these two types of chest pain, since the treatment plans are different.

During the patient's process of grieving for the losses resulting from spinal cord injury, the nurse a. helps the patient understand that working through the grief will be a lifelong process b. should assist the patient to move through all stages of the mourning process to acceptance c. lets the patient know that anger directed at the staff or the family is not a positive coping mechanism d. facilitates the grieving process so that it is completed by the time the patient is discharged from rehabilitation

A. helps the patient understand that working through the grief will be a lifelong process

A nurse assess a patient with ALS. Which assessment findings are consistent with this patient's diagnosis? a. muscle weakness and atrophy b. paresthesias and visual disturbances c. ascending paralysis and respiratory distress d. decreased cognition and bladder dysfunction

A. muscle weakness and atrophy These are the clinical manifestations of ALS. Paresthesias and visual disturbances are manifestations of multiple sclerosis. Ascending paralysis that may lead to respiratory distress is indicative of Guillan-Barre Syndrome. A patient with ALS retains cognition throughout the disease process.

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses' greatest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

A. prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A patient is admitted to the hospital with Guillain-Barre syndrome. She had a weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of her illness, the nurse recognizes that a. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity b. early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damages c. although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease d. the most serious complication of this condition is ascending demyelination of the peripheral nerves of the lower brainstem and cranial nerves

A. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity Rationale: The most serious complication of GBS is respiratory failure, and it is essential that respiratory rate, depth, and vital capacity are monitored to detect involvement of the nerves that affect respiration. Corticosteroids may be used in treatment but do not appear to have an effect on the prognosis or duration of the disease. Rather, plasmapheresis or administration of high dose immunoglobulin does result in shortening recovery time. The peripheral nerves of both the sympathetic and parasympathetic NS are involved in the disease and may lead to orthostatic hypotension, hypertension, and may abnormal vagal responses affecting the heart.

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

A: Place objects on the right side within the patient's field of vision- the presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient regarding a. the need to avoid high-voltage electrical fields. b. how to monitor anticoagulation therapy. c. the need for valve replacement in 7 to 10 years. d. how to check the radial pulse.

B Rationale: Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. There is no need to avoid high-voltage electrical fields. Mechanical valves are durable and would last longer than 7 to 10 years. Monitoring of radial pulse is not necessary after valve replacement.

A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis? a. Audible crackles at both lung bases b. 3+ edema in the lower extremities c. Loud murmur at the mitral area d. High systemic BP

B Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distension, and right upper-quadrant abdominal tenderness would be expected. Lung crackles, a murmur, and numbness and tingling are not caused by cor pulmonale.

Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be communicated to the health care provider immediately? a. The patient has a loud diastolic murmur all across the precordium. b. The patient has crackles audible to the lung apices. c. The patient has a palpable thrill felt over the left anterior chest. d. The patient has 4+ peripheral edema in both legs.

B Rationale: Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure and needs immediate interventions such as diuretics. A diastolic murmur and palpable thrill would be expected in a patient with mitral stenosis. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

Which of these assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Blood pressure (BP) of 166/96 b. Jugular vein distension (JVD) to the level of the jaw c. Pulsus paradoxus 8 mm Hg d. Level 6/10 chest pain with deep inspiration

B Rationale: The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.

The patient has rhinorrhea after a head injury. What action should you take? A. Pack the nares with sterile gauze. B. A loose collection pad may be placed under the nose. C. Suction the drainage with an inline suction catheter. D. Obtain a sample for culture.

B. A loose collection pad may be placed under the nose. A loose collection pad may be placed under the nose. Do not place a dressing in the nasal cavity, and nothing should be placed inside the nostril. There is no need to culture the drainage. The concern is whether it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.

You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B. Bradycardia Changes in vital signs indicative of increased ICP are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety. b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility.

B. control blood pressure. Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.

You plan care for the patient with increased ICP with the knowledge that the best way to position the patient is to A. keep the head of the bed flat. B. elevate the head of the bed to 30 degrees. C. maintain patient on the left side with the head supported on a pillow. D. use a continuous-rotation bed to continuously change patient position.

B. elevate the head of the bed to 30 degrees. You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP and the CPP is required.

A nurse is positioning a client with increased ICP. Which position would the nurse avoid? A. head midline B. head turned to the side C. neck in neutral position D. head of bed elevated 30-45 degrees

B. head turned to the side The head of a client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side . The head of the bed should be raised 30-45 degrees . Use of proper position promotes venous drainage from the cranium to keep ICP down

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

C: Daily low dose aspirin- the administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses' best response to the patient is, a. it is really still too soon to know if you will have a return of function b. the could be a really positive finding. can you show me the movement c. that's wonderful. we will start exercising your legs more frequently now d. im sorry, but the movement is only a reflex and does not indicate normal function

B. the could be a really positive finding. can you show me the movement Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function, but with the resolution of edema, some normal function may also occur. it is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour. B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields.

C LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.

The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis. Which question by the nurse is most appropriate? a. "Do you have a history of a heart attack?" b. "Have you any recent immunizations?" c. "Have you been to the dentist lately?" d. "Is there a family history of endocarditis?"

C Rationale: Dental procedures place the patient with a prosthetic mitral valve at risk for infectious endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The most appropriate intervention by the nurse for this problem is to a. force fluids to 3000 ml/day to decrease fever and inflammation. b. teach the patient to take deep, slow respirations to control the pain. c. position the patient in Fowler's position, leaning forward on the overbed table. d. remind the patient to ask for the opioid pain medication every four hours.

C Rationale: Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).

A patient hospitalized with IE develops sharp left flank pain and hematuria. The nurse notifies the health care provider, recognizing that these symptoms may indicate a. septicemia. b. acute pyelonephritis. c. vegetative embolization. d. glomerulonephritis.

C Rationale: The patient's clinical manifestations and history of IE indicate embolization. Sudden onset flank pain is not typical of pyelonephritis, septicemia, or glomerulonephritis.

The nurses discusses treatment options with a patient who has trigeminal neuralgia. The nurse recognizes the need for further teaching when the patient says which of the follow statements: A. "A nerve block will help with the intermittent pain." B. "Anticonvulsant medications help stabilize the sensory nerves, so pain will decrease." C. "Antibiotics will fight the infection that started this pain." D. "I should avoid triggers, like heat, cold, or chewing, that cause the pain exacerbations."

C. "Antibiotics will fight the infection that started this pain." The pathology of trigeminal neuralgia is not related to an infectious process, so antibiotics will not help decrease the patient's pain episodes.This statement by the patient indicates a need for further teaching.

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

Priority nursing measures after an abdominal aortic aneurysm repair include a. assessment of cranial nerves and mental status. b. administration of IV heparin and monitoring of aPTT. c. administration of IV fluids and monitoring of kidney function. d. elevation of the legs and application of elastic compression stockings

C. administration of IV fluids and monitoring of kidney function. Rationale: Postoperative priorities include administration of IV fluids and maintenance of renal perfusion. An adequate blood pressure is important for maintaining graft patency, and administration of IV fluids and blood components (as indicated) is essential for adequate blood flow. The nurse should evaluate renal function by measuring hourly urine output and monitoring daily blood urea nitrogen (BUN) and serum creatinine levels. Irreversible renal failure may occur after aortic surgery, particularly in individuals at high risk.

During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses' first action should be to a. initiate frequent turning and repositioning b. use tracheal suctioning to remove secretions c. assess lung sounds and respiratory rate and depth d. prepare the patient for endotracheal intubation and mechanical ventilation

C. assess lungs sounds and respiratory rate and depth Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing function, the nurse should assess the patient's breath sound and resp function to determine whether secretions are being retained or whether there is progression of resp impairment. Suctioning is not indicated unless lung sounds indicate retained secretions: position changes will help mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if ABGs deteriorate

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

C. c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable.

Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of small cutaneous arteries in the feet. b. increase in retrograde venous blood flow in the legs. c. decrease in arterial blood flow to the nerves of the feet. d. decrease in arterial blood flow to the leg muscles during exercise.

C. decrease in arterial blood flow to the nerves of the feet. Rationale: Rest pain most often occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain occurs when blood flow is insufficient to meet basic metabolic requirements of the distal tissues. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.

A patient with Guillain-Barre syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, the nurse knows that a. patient who require ventilatory support almost always die b. death occurs when nerve damage affects the brain and meninges c. most patient with Guillain-Barre syndrome make a complete recovery d. if death can be prevented, residual paralysis and sensory impairment are usually permanent

C. most patient with Guillain-Barre syndrome make a complete recovery Rationale: As nerve involvement ascends, it is very frightening for the patient, but most patients with GBS recover completely with care. Patients also recover if ventilatory support is provided during respiratory failure. GBS affects only peripheral nerves and does not affect the brain

A patient with pericarditis reports increasing chest pain. The nurse further assess the patient's pain. Which on the following manifestations leads the nurse to believe that the patient is experiencing a myocardial infarction? A. pain increases with deep breathing and lying flat B. pain is relieved with sitting up and leaning forward C. pain is described as crushing pressure, lasting more than 30 minutes D. pleural fricition rub is heard upon ausculation

C. pain is described as crushing pressure, lasting more than 30 minutes The other answer choices are expected findings for a patient with pericarditis.

Clinical manifestations of a compressed nerve in the lumbosacral region include all of the following except: a. sharp, severe lower back pain b. difficulty starting and stopping urination c. pain relieved by rest and heat packs d. paresthesias and weakness in the legs

C. pain relieved by analgesics. A compressed nerve in the lumbosacral region will manifest a sharp, severe pain in the lower back area, with difficulty starting and stopping the stream or urine, and paresthesias and weakness in the legs. All these manifestations are a result of compression on the nerve root. Since this is nerve pain, the pain will not be alleviated by rest and heat packs.

Without surgical stabilization, immobilization and traction of the patient with a cervical spinal cord injury most frequently requires the use of a. kinetic beds b. hard cervical collars c. skeletal traction with skull tongs d. sternal-occipital-mandibular immobilizer (SOMI) brace

C. skeletal traction with skull tongs Rationale: Cervical injuries usually require skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs to immobilize the cervical vertebrae, even if fracture has not occurred. Hard cervical collars are used for minor injuries or for stabilization during emergency transport of the patient. Sandbags are also used temporarily to stabilize the neck during insertion of tongs or during diagnostic testing immediately following the injury. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervcal traction.

When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are: a. weight and diet. b. activity level and diet. c. tobacco use and high blood pressure. d. sedentary lifestyle and high blood pressure.

C. tobacco use and high blood pressure Rationale: Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

C: Individuals with hypertension and diabetes- The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke- An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.

Correct Answer: C Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

6. A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. offer the patient liquid nutritional supplements at frequent intervals. c. discuss the patient's concerns with visitors who arrive at mealtimes. d. teach the patient to chew food on the unaffected side of the mouth.

Correct Answer: A Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.

Correct Answer: A Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. decreased sensation on the affected side.

Correct Answer: A. Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: C Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

Correct Answer: C Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.

Correct Answer: D Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. ineffective airway clearance related to thick secretions. c. impaired transfer ability related to weakness. d. impaired gas exchange related to respiratory congestion.

D Rationale: All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

During the assessment of a patient with IE, the nurse would expect to find a. substernal chest pain and pressure. b. splinter hemorrhages of the lips. c. dyspnea and a dry, hacking cough. d. a new regurgitant murmur.

D Rationale: New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Splinter hemorrhages occur on the nailbeds. Chest pain for pressure is not typical for the patient with IE and would be more consistent with angina or MI. Although dyspnea may occur as a result of heart failure, a moist cough would be expected rather than a dry, hacking cough.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Resting pulse oximetry (SpO2) of 85% b. Respiratory rate of 28 c. Large amounts of greenish sputum d. Weak, nonproductive cough effort

D Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)? A. Heart rate increases from 90 to 110 beats/minute B. Kussmaul respirations C. Temperature over 100.4° F (38° C) D. Heart rate decreases from 75 to 55 beats/minute .

D. Heart rate decreases from 75 to 55 beats/minute Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad

In planning community education for prevention of spinal cord injuries, the nurse targets a. elderly men b. teenage girls c. elementary school-age children d. adolescent and young adult men

D. adolescent and young adult men Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence.

A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities? A. blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning

D. exhaling during repositioning (activities that increase intra-throacic and intra-abdominal pressures cause indirect elevation of the ICP. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intra-thoracic pressure from rising).

A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c. loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise ventilator support as needed is the priority intervention.

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning- the patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, a. you will have more normal function when spinal shock resolves and the reflex arc returns b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved

Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension b A 40-year-old female with obesity and metabolic syndrome c A 60-year-old male with renal insufficiency who is physically inactive d A 65-year-old female with hyperhomocysteinemia and substance abuse

a A 70-year-old male, with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? a Buerger's disease b Venous thrombosis c Acute arterial ischemia d Raynaud's phenomenon .

a Buerger's disease Rationale: Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose

The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? a Rest pain b High blood pressure c Elevated blood sugar d Dry, itchy, flaky skin

a Rest pain Rationale: Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

A 38-year-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse what is going to happen to her. What is the best response by the nurse? a. "You will have either periods of attacks and remissions or progression of nerve damage over time." b. "You need to plan for a continuous loss of movement, sensory functions, and mental capabilities." c. "You will most likely have a steady course of chronic progressive nerve damage that will change your personality." d. "It is common for people with MS to have an acute attack of weakness and then not to have any other symptoms for years."

a. "You will have either periods of attacks and remissions or progression of nerve damage over time." Most patients with multiple sclerosis (MS) have remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course followed by progression with or without occasional relapses, minor remissions, and plateaus that progressively cause loss of motor, sensory, and cerebellar functions. Intellectual function generally remains intact but patients may experience anger, depression, or euphoria. A few people have chronic progressive deterioration and some may experience only occasional and mild symptoms for several years after onset.

A key aspect of teaching for the patient on anticoagulant therapy includes which instructions? a. Monitor for and report any signs of bleeding. b. Do not take acetaminophen (Tylenol) for a headache. c. Decrease your dietary intake of foods containing vitamin K. d. Arrange to have blood drawn routinely to check drug levels.

a. Monitor for and report any signs of bleeding. Rationale: Patients taking anticoagulants should be taught to monitor and report any signs of bleeding, which can be a serious complication. Other important patient teaching includes maintenance of a consistent intake of foods containing vitamin K, avoidance of supplements that contain vitamin K, and routine coagulation laboratory studies if a patient is taking warfarin.

A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine d. assessing the patient's motor and sensory function

a. maintaining a patent airway Rationale: The need for a patent airway is the first priority for any injured patient, and a high cervical injury may decrease the gag reflex and ability to maintain an airway, as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patients neuro status.

A patient with Bell's Palsy has right sided facial paralysis. She is no longer able to close her right eyelid or chew on the affected side of the mouth. The patient is weeping and withdrawn. The nurse's priority action is to: a. protect the cornea with lubricating eye drops b. respect the patient's privacy because of her body image concerns c. comfort the patient with therapeutic silence d. Report theses findings to the physician

a. protect the cornea with lubricating eye drops Protect the cornea!!!!! :)

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: a.) A positive Brudzinski's sign b.) A negative Kernig's sign c.) Absence of nuchal rigidity d.) A Glascow Coma Scale score of 15

a.) A positive Brudzinski's sign Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a Patient complains of chest pain with strenuous activity. b Patient says muscle leg pain occurs with continued exercise. c Patient has numbness and tingling of all his toes and both feet. d Patient states the feet become red if he puts them in a dependent position.

b Patient says muscle leg pain occurs with continued exercise. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? a Gender b Smoking c Ethnicity d Co-morbidities

b Smoking Rationale: Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? a Assess output for renal dysfunction. b Use IV fluids to maintain adequate BP. c Use oral antihypertensives to maintain cardiac output. d Maintain a low BP to prevent pressure on surgical site

b Use IV fluids to maintain adequate BP. Rationale: The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.

When providing care for a patient with ALS, the nurse recognizes what as one of the most distressing problems experienced by the patient? a. Painful spasticity of the face and extremities b. Retention of cognitive function with total degeneration of motor function c. Uncontrollable writhing and twisting movements of the face, limbs, and body d. Knowledge that there is a 50% chance the disease has been passed to any offspring

b. Retention of cognitive function with total degeneration of motor function In ALS there is gradual degeneration of motor neurons with extreme muscle wasting from lack of stimulation and use. However, cognitive function is not impaired and patients feel trapped in a dying body. Chorea manifested by writhing, involuntary movements is characteristic of HD. As an autosomal dominant genetic disease, HD also has a 50% chance of being passed to each offspring.

In preparation for discharge of a patient with arterial insufficiency and Raynaud's disease, the nurse needs to include which teaching instructions? a. walk several times each day for exercise b. adjust the home thermostat to keep your environment warm c. wear TED hose during the day to facilitate circulation d. consider hydrotherapy to increase circulation

b. adjust the home thermostat to keep your environment warm Raynaud's disease is characterized by vasospasms, triggered by cold, stress or vibrations. With peripheral arterial insufficiency, patient should not wear tight clothing, because we want to get arterial blood down to the legs. Hydrotherapy and walking may help with the arterial insufficiency but won't do much for the Raynaud's disease.

A nurse is assessing the neurovascular (NV) status of a patient who returned to the floor 4 hours ago after undergoing an aortoiliac bypass graft. The surgical leg is warm, red, and slightly edematous. The pedal pulse is palpable and unchanged from admission. How does the nurse interpret the NV status of this patient? a. slightly deteriorating and should be monitored for another hour b. these are normal and expected findings c. moderately impaired and the surgeon should be notified d. adequate from the arterial approach, but venous complications are occurring

b. these are normal and expected findings Warmth, redness, and swelling in the surgical leg post aortoiliac bypass graft surgery are normal and expected findings. The indicate that blood is flowing to the area.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF)

b.) Intracranial pressure (ICP) is increased Rationale: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? a.) Absence of pain sensation in chest b.) Spasticity c.) Spontaneous respirations d.) Urinary continence

b.) Spasticity Rationale: Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess? a Improved skin turgor b Decreased cardiac rate c Improved finger perfusion d Decreased mean arterial pressure

c Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.

During assessment of a patient admitted to the hospital with an acute exacerbation of MS, what should the nurse expect to find? a. Tremors, dysphasia, and ptosis b. Bowel and bladder incontinence and loss of memory c. Motor impairment, visual disturbances, and paresthesias d. Excessive involuntary movements, hearing loss, and ataxia

c. Motor impairment, visual disturbances, and paresthesias Specific neurologic dysfunction of MS is caused by destruction of myelin and replacement with glial scar tissue at specific areas in the nervous system. Motor, sensory, cerebellar, and emotional dysfunctions, including paresthesias as well as patchy blindness, blurred vision, pain radiating along the dermatome of the nerve, ataxia, and severe fatigue, are the most common manifestations of MS. Constipation and bladder dysfunctions, short-term memory loss, sexual dysfunction, anger, and depression or euphoria may also occur. Excessive involuntary movements and tremors are not seen in MS.

An initial incomplete spinal cord injury often results in complete cord damage because of a. edematous compression of the cord above the level of the injury b. continued trauma to the cord resulting from damage to stabilizing ligaments c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment Rationale: A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care? a.) Provide good perineal care. b.) Pass nasogastric tube to decompress stomach. c.) Keep client warm with extra blankets. d) Stimulate the anal-rectal reflex. s

c.) Keep client warm with extra blankets. Rationale: Poikilothermia is a loss of temperature control and is dangerous because the client's body temperature will depend upon the temperature in the environment. The client needs to be kept warm and monitored carefully to avoid thermal injuries from passive warming device

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? a Tamponade will soon occur. b The renal arteries are involved. c Perfusion to the legs is impaired. d He is bleeding into the abdomen.

d He is bleeding into the abdomen. Rationale: The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

A patient comes to the outpatient clinic and tells the nurse that he has leg pains that begin when he walks, but the pain goes away when he stops walking. What will the nurse assess for? a. acute obstruction in the vessels of the legs b. calcium deficiency c. vasospasms of the small arteries d. peripheral vascular insufficiency in the legs

d. peripheral vascular insufficiency in the legs Intermittent claudication is a sign of chronic peripheral vascular insufficiency. S&S of an acute obstruction would be sudden and sever pain in the extremity, with decreased/no pulse, and pallor/cyanotic coloring. Acute arterial obstructions are a medical emergency.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? a.) Place the client flat in bed b.) Assess patency of the indwelling urinary catheter c.) Give one SL nitroglycerin tablet d.) Raise the head of the bed immediately to 90 degrees

d.) Raise the head of the bed immediately to 90 degrees Rationale: Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports C: Teach the patient to care consciously for

the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.