Neuro - NCLEX Style Questions
Client with a spinal cord injury suddenly experiences autonomic dysreflexia. After checking the clients vs , put in order from highest priority the next actions
1st raise head of bed 2nd loosen tight clothing 3rd check bladder for distention 4th contact hcp 5th give antihypertensive med 6th document occurrence , treatment and response (pt can have a hypertensive stroke if this not controlled)
A nurse is caring for a client who has suffered spinal cord injury. The nurse further monitors the client for autonomic dysreflexia and suspects this complication if which of the following is noted? A. sudden tachycardia 2. pallor of the face and neck 3. severe, throbbing headache 4. severe and sudden hypotension
3. severe, throbbing headache (The client with a spinal cord injury above level T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea and sweating. It is a life threatening condition triggered by a noxious stimulus below level of injury)
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of recurrence? 1. strict adherence to a bowel retraining program 2. keeping the linen wrinkle free under the client 3. avoiding unnecessary pressure on the lower limbs 4. limiting bladder catheterization to once every 12 hours
4. limiting bladder cath to once q12h (the most frequent cause of autonomic dysreflexia is a distended bladder . Straight cath shoul be performed q4-6 hrs and foley cath should be checked frequently for kinks in tubing . Constipation and fecal impaction are other causes, so maintaining bowel irregularity is important .
A client has just undergone computed tomography ( CT) scanning with a contrast medium. The nurse determines that the client understands post procedure care if the client verbalizes that he or she will: A. drink extra fluids for the day B. hold meds for at least 4 hours C. Eat lightly for the remainder of the day D. Rest quietly for the remainder of the day
A. drink extra fluids for the day (after a ct scanning the client may resume all usual activities. the client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye)
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)
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 nurse is caring for a client with increased intracranial pressure (ICP). the nurse should monitor for what vital signs that would occur if ICP is rising
increased temp, decreased pulse, decreasing respirations, and increasing bp (a change in vital signs may be a late sign of increased ICP)
A client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, the nurse immediately should:
raise head of bed and remove noxious stimulant (key nursing actions are to sit client up in bed. remove stimulus and control BP with antihypertensive med per protocol. The nurse should label the chart that pt is at risk for this. Client and family should be taught the signs of this syndrome.
A client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?
side lying, with legs pulled up and head bent down onto the chest (the client undergoing an LP is positioned lying on the side, with legs pulled up to the abdomen and the head bent down onto the chest . This position helps open the spaces between the vertebrae)