NRSG 337 - Exam 4

Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.

1

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

2, 4, 5

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. Should the nurse avoid which measure to minimize the risk of occurrence? 1. Strict adherence to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Preventing unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours

4

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.

4

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

74 CPP = (MAP - ICP) MAP = (SBP + [2x DBP]) / 3 The MAP is 94 - ICP 20 = 74

Endocrine disorders often go unrecognized in the older adult because a. symptoms are often attributed to aging. b. older adults rarely have identifiable symptoms. c. endocrine disorders are relatively rare in the older adult. d. older adults usually have subclinical endocrine disorders that minimize symptoms.

A

Hypoglycemic unawareness in some patients can be the result of use of A. beta blockers. B. insulin. C. thiazides. D. incretin mimetics.

A

Tetany is a clinical manifestation related to _______ calcium levels and is usually due to a _______ gland dysfunction. A. Low; parathyroid B. High; parathyroid C. High; thyroid D. Low; thyroid

A

The client with a traumatic brain injury from a motor vehicle accident is monitored for signs in Increased Intracranial Pressure (ICP). Which sign does the nurse monitor for? A. Change in breathing pattern B. Dizziness C. Increased level of consciousness D. Reactive pupils

A

When obtaining subjective data from a patient during assessment of the endocrine system, the nurse asks specifically about a. energy level. b. intake of vitamin C. c. employment history. d. frequency of sexual intercourse.

A

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? A. Increasing serum sodium levels B. Decreasing serum chloride levels C. Decreasing blood glucose levels D. Increasing serum potassium levels

A

Which of the following medications are administered for preventive therapy in the treatment of migraine? A) beta-adrenergic blockers B) nonsteroidal anti-inflammatory agents C) ergot alkaloids D) analgesics

A

Which statement accurately describes Graves' disease? a. Exophthalmos occurs in Graves' disease. b. It is an uncommon form of hyperthyroidism. c. Manifestations of hyperthyroidism occur from tissue desensitization to the sympathetic nervous system. d. Diagnostic testing in the patient with Graves' disease will reveal an increased thyroid-stimulating hormone (TSH) level.

A

The nurse is admitting a client who has been diagnosed with Addison's disease. Which signs and symptoms support this diagnosis? a. Bronze pigmentation, hypotension, and hyponatremia b. Moon face, buffalo hump, and hyperglycemia c. Hirsutism, fever, irritability d. Tachycardia, bulging eyes, goiter

A ((bronze pigmentation from excess ACTH as the anterior pituitary tries to prompt the adrenal cortex to release hormones; hypotension and hyponatremia from lack of mineral corticoids) B and C are not correct as almost all the s/sx are associated with Cushing syndrome (excess corticosteroids); D is not correct as the s/sx would be expected with hyperthyroid)

Cardiac monitoring is initiated for a patient receiving treatment for diabetic ketoacidosis. The nurse recognizes that this measure is important to identify A. dysrhythmias resulting from hypokalemia. B. fluid overload resulting from aggressive fluid replacement. C. the presence of hypovolemic shock related to osmotic diuresis. D. cardiovascular collapse resulting from the effects of excess glucose on cardiac cells.

A (Electrolytes are depleted in diabetic ketoacidosis due to osmotic diuresis. Potassium is expected to fall further as insulin is administered (glucose and potassium will move from the vascular space into cells).. Hypokalemia may lead to ventricular dysrhythmias such as premature ventricular complexes and bradycardia.)

A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On physical assessment of the patient, what should the nurse expect to find? A. Hypertension, abnormal hair growth, and easy bruising. B. Weight loss, buffalo hump, and moon face with acne. C. Abdominal and buttock striae, truncal obesity, and hypotension. D. Anorexia, signs of dehydration, and hyperpigmentation of the skin.

A (HTN from excess mineralcorticoids; abnormal hair growth from excess androgens; easy bruising from excess glucocorticoids) B is not correct as we'd expect weight gain, not loss; C is not correct as we'd expect hypertension, not hypotension; D is not correct as all listed s/sx are what we'd expect with a lack of corticosteroids, not an excess.)

Primary adrenal insufficiency: caused by destruction of adrenal tissue (Addison's disease). What would you expect serum ACTH to be? A. high B. low

A (Patient's disease resulted in destruction of adrenal cortex tissue. The anterior pituitary doesn't realize this (but knows levels of corticosteroids in the body are too low) and keeps secreting more and more ACTH in hopes of activating the adrenal cortex to action.)

If caused by a pituitary tumor (Cushing's disease), what would you expect serum ACTH to be? A. high B. low

A (This patient has Cushing's disease - a specific type of Cushing's Syndrome with it's own pathophysiology (a tumor in the anterior pituitary that secretes too much ACTH and doesn't follow the normal regulatory mechanisms). Consequently, this patient's ACTH will be high.)

A student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. The student understands which categories of client functioning are included in this assessment? Select all that apply. A. Eye opening B. Best verbal response C. Best motor response

A, B, C

What are clinical manifestations of Hypothyroidism? Select all that apply. A. Weight gain B. Low exercise tolerance C. Increased metabolic processes D. Increased sensitivity to opioids

A, B, D

What are common manifestations of Hyperthyroidism? Select all that apply. A. Diarrhea B. Intolerance to cold C. Nervousness D. Goiter

A, C, D

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

A, D, E, F

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about A. bisphosphonates to reduce bone demineralization. B. calcium supplements to normalize serum calcium levels. C. increasing fluid intake to decrease risk for nephrolithiasis. D. including whole grains in the diet to prevent constipation.

B (needs long term calcium replacement)

In evaluating the effectiveness of treatment for acromegaly the nurse would monitor (select all that apply) A. ADH levels B. GH levels C. Serial Photography D. Height and Weight

B, C

Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.

B, E

Which nursing assessment of a 70 year old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? A. Fluid balance B. Apical pulse rate C. Nutritional intake D. Orientation and alertness

B (Cardiac assessment is key)

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? A. Suction the patient's airway. B. Administer IV calcium gluconate. C. Plan for emergency tracheostomy. D. Prepare for endotracheal intubation.

B (laryngeal spasm; pt has tetany)

A client with myasthenia gravis arrives at the hospital emergency department in a suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crisis. The nurse ensures that which medication is available in the event that the client is in a cholinergic crisis?

Atropine sulfate

A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? A. "Have you had a recent head injury?" B. "Do you have to wear larger shoes now?" C. "Is there a family history of acromegaly?" D. "Are you experiencing tremors or anxiety?"

B

A characteristic common to all hormones is that they a. circulate in the blood bound to plasma proteins. b. influence cellular activity of specific target tissues. c. accelerate the metabolic processes of all body cells. d. enter a cell to alter the cell's metabolism or gene expression.

B

A nurse is assessing a client for changes in the LOC using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following is the correct scoring by the nurse using the scale that indicates the client has a moderate head injury? a. E2+ V3 + M5 = 10 b. E3 + V4 + M4 = 11 c. E4 + V5 + M6 = 15 d. E2 + V2 + M4 = 8

B

During discharge teaching for the patient with Addison's disease, which statement by the patient indicates that the nurse needs to do additional teaching? a. "I should always call the doctor if I develop vomiting or diarrhea." b. "If my weight goes down, my dosage of steroid is probably too high." c. "I should double or triple my steroid dose if I undergo rigorous physical exercise." d. "I need to carry an emergency kit with injectable hydrocortisone in case I can't take my medication by mouth."

B

A nurse is cautioning a patient with diabetes mellitus about the dangers of developing diabetic ketoacidosis (DKA). Which of the following situations should the nurse alert the patient is a possible cause of DKA? A. Feeling stressed B. Infection C. Excess insulin D. Insufficient calories in the diet

B (B = common cause of DKA. Simply feeling stressed should not cause DKA, though extreme physiologic or emotional stress (especially if it affects patient's disease self-management), could. Excess insulin and insufficient calories in diet will cause hypoglycaemia.)

If caused by exogenous cortisol (meds), what would you expect serum ACTH to be? A. high B. low

B (Patient has excess glucocorticoid (cortisol) from the meds he is taking (imagine a patient taking high doses for RA, etc.). His anterior pituitary recognizes there is plenty of cortisol in the body (it doesn't care that it got there from meds) and decreases/stops release of ACTH (similar to how a thermostat stops sending the "on" message to a furnace once there is enough heat in the house). Note that - in the absence of this message - the patient's adrenal cortex does not secrete glucocorticoids either (the HPA axis is on vacation); however, the patient still shows s/sx of Cushing's Syndrome due to the high doses he is getting in his meds.)

The nurse determines that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient's A. Weight has increased B. Urinary output has increased C. Peripheral edema is increased D. Urine specific gravity is increased

B (Question used to try to illustrate that you can figure out the answer even if you can't recognize the name of the med. Hopefully, you'll remember that patient's with SIADH who need meds may get a loop diuretic or a med that blocks ADH or its receptor. This isn't a loop diuretic, so it must be the latter. Critical thinking would tell us we will know the patient who is being treated for SIADH is improving if he/she has less water resorption which would manifest of increased elimination of more dilute urine (decreased specific gravity), decreased weight and decreased edema. B is the only correct answer. All others describe what we would expect to see if the patient's SIADH was getting worse.)

Secondary adrenal insufficiency: caused by a pituitary problem. What would you expect serum ACTH to be? A. high B. low

B (The patient suffered damage to the anterior pituitary so it cannot release ACTH (levels are low).)

If Cushing's Syndrome is caused by adrenal tumor, what would you expect serum ACTH to be? A. high B. low

B (This patient has Cushing's Syndrome (per the top of the slide). It is caused by tumor in the adrenal gland itself, resulting in too much release of corticosteroids (likely all three categories). His anterior pituitary recognizes there is plenty of corticosteroids in the body and (similar to above) decreases/stops release of ACTH. Even though the healthy adrenal tissue will not release corticosteroids in the absence of the message from the anterior pituitary (ACTH), the tumor is dysfunctional tissue and keeps releasing the corticosteroid anyway.)

The nurse is caring for a client diagnosed with Addison's disease. Which nursing interventions should be implemented? A. Place the client in contact isolation. B. Administer intravenous and/or oral steroid medications as ordered C. Provide a brightly lit room and recreational activities. D. Consult with occupational therapy for work retraining.

B (need to ADD steroids by administering replacement meds. A is not necessary; C would increase stress (calm environment needed); D is not a priority.)

The nurse is caring for a patient recently started on levothyroxine for hypothyroidism. What information reported by the patient requires immediate action? A. Weight gain or loss B. Chest pain and palpitations C. Muscles weakness and fatigue D. Decreased appetite and constipation

B (Cardiac assessment is key)

Hormone that stimulates synthesis and release of thyroid hormones, growth and function of thyroid gland

Thyroid-Stimulating Hormone (TSH)

. A patient is admitted to the hospital with acute thyrotoxicosis. On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and laryngeal stridor b. Bulging eyeballs and dysrhythmias c. Elevated temperature and signs of heart failure d. Lethargy progressing suddenly to impairment of consciousness

C

A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor? A. Total protein B. Blood glucose C. Ionized calcium D. Serum phosphate

C

A patient with known primary adrenocortical insufficiency comes to the Emergency Department (E.D.) with hypotension, hyponatremia, hyperkalemia, fever and confusion. A diagnosis of Addisonian crisis is made. The nurse would expect the E.D. physician to order which of the following to be given intravenously? A. ACTH B. Blood C. Hydrocortisone D. Diuretics

C

A patient with mild iatrogenic Cushing syndrome is on an alternate-day regimen of corticosteroid therapy. What does the nurse explain to the patient about this regimen? a. It maintains normal adrenal hormone balance. b. It prevents ACTH release from the pituitary gland. c. It minimizes hypothalamic-pituitary-adrenal suppression. d. It provides a more effective therapeutic effect of the drug.

C

An appropriate technique to use during physical assessment of the thyroid gland is a. asking the patient to hyperextend the neck during palpation. b. percussing the neck for dullness to define the size of the thyroid. c. having the patient swallow water during inspection and palpation of the gland. d. using deep palpation to determine the extent of a visibly enlarged thyroid gland.

C

Common nonspecific manifestations that may alert the nurse to endocrine dysfunction include A. Goiter and alopecia B. Exophthalmos and tremors C. Weight loss, fatigue, and depression D. Polyuria, polydipsia, and polyphagia

C

The hypothalamus secretes releasing hormones and inhibiting hormones. What is the target tissue of these releasing hormones and inhibiting hormones? A. Pineal B. Adrenal cortex C. Anterior pituitary D. Posterior pituitary

C

Which endocrine gland secretes cortisol? A. Ovaries B. Thyroid C. Adrenal Cortex D. Adrenal Medulla

C

Which question from a nurse during a patient interview will provide focused information about a possible thyroid disorder? A. "What methods do you use to help cope with stress?" B. "Have you experienced any blurring or double vision?" C. "Have you had a recent unplanned weight gain or loss?" D. "Do you have to get up at night to empty your bladder?"

C

Your patient has a new diagnosis of Cushing syndrome (hypercortisolism). You know that the most common cause of this disorder is: A. Adrenal carcinoma B. Pituitary tumor C. Long term non-replacement steroid therapy D. Overreaction to stress

C

Your patient is admitted to the hospital with a diagnosis of hyperaldosteronism. Which of the following assessment and diagnostic findings would require an immediate response from the nurse? A. Blood pressure of 148/92 B. Fasting blood glucose of 135 mg/dl C. Serum potassium level of 2.4 mEq/L D. Serum pH of 7.44

C

A 56-yr-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n) A. Elevated hematocrit B. Increased serum chloride C. Decreased serum sodium D. Low urine specific gravity

C (Remember that the patient with SIADH is retaining too much water, resulting in low urine output of concentrated urine (would have a high specific gravity). Water resorption/retention will dilute RBCs (resulting in decreased hematocrit), dilute serum chloride (the negative ion counterpart to positively charged sodium). Therefore, only "C" is correct: sodium will decrease (become more diluted), too.)

The client admitted for chronic obstructive pulmonary disease (COPD) has developed Cushing's syndrome. What is the scientific rationale for the development of this problem? A. The client's chronic lack of oxygen has destroyed the adrenal glands. B. The client has a pituitary tumor that causes an overproduction of cortisol. C. The client has been taking steroid medications for an extended time. D. It cannot be explained.

C (patients with COPD often need corticosteroid medications to decrease respiratory inflammation; this could lead to Cushing's syndrome from exogenous administration of high doses)

An 82 year old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed A. Docusate B. Ibuprofen C. Diazepam D. cefoxitin

C (Inc sensitivity to these meds)

A patient who smokes reports having significant stress and is experiencing eye problems. On assessment, the nurse notes exophthalmos. What additional abnormal findings should the nurse assess for? A. Muscle weakness and slow movements B. Puffy face, decreased sweating, and dry hair C. Systolic hypertension and increased heart rate D. Decreased appetite, increased thirst, and pallor

C (Possible Grave's)

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to A. Cough and deep breath every 2 hours postoperatively B. Remain on bedrest for the first 48 hours after the surgery C. Avoid brushing teeth for at least 10 days after surgery D. Be positioned flat with sandbags at the head postoperatively

C (due to incision location)

The nurse working in an acute care environment would utilize which strategies to reduce the risk of malpractice litigation. SATA A. Discuss any errors in the client and family in detail B. Keep incident reports on file C. Maintain expertise in practice D. Offer opinions to clients when situations warrants E. Reports unsafe staffing levels to supervisors.

C, E

Injuries above what level requires immediate intubation and mechanical ventilation?

C4

What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence?

Choose between two outfits to wear each morning.

Hormone that regulates metabolic rate of all cells and processes of cell growth and tissue differentiation.

Triiodothyronine (T3)

Hormone that promotes metabolism. Increase in response to stress. Anti-inflammatory.

Corticosteroids

A 32-year-old woman has been taking ergotamine tartrate as abortive therapy for migraine headache for many years. For which of the following adverse effects does the nurse assess? A) hypotension B) muscle weakness C) hypoventilation D) valvular fibrosis

D

The health care provider prescribes levothyroxine (Synthroid) for a patient with hypothyroidism. After teaching regarding this drug, the nurse determines that further instruction is needed when the patient says A. " I will report any chest pain or difficulty breathing to the doctor right away." B. "I can expect to return to normal function with the use of this drug." C. " I can expect the medication dose may need to be adjusted." D. "I only need to take this drug until my systems are improved."

D

What manifestations of endocrine problems in the older adult are commonly attributed to the aging process? A. Tremors and paresthesia B. Hyperpigmentation and oily skin C. Fluid retention and hypertension D. Fatigue and mental impairment

D

When providing discharge instructions to a patient who had a subtotal thyroidectomy for hyperthyroidism, what should the nurse teach the patient? a. Never miss a daily dose of thyroid replacement therapy. b. Avoid regular exercise until thyroid function is normalized. c. Use warm saltwater gargles several times a day to relieve throat pain. d. Substantially reduce caloric intake compared to what was eaten before surgery.

D

Which statement by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be necessary? A. "I notice my breasts are tender lately." B. "I am so thirsty that I drink all day long." C. "I get up several times at night to urinate." D. "I feel a lump in my throat when I swallow."

D

a patient with Parkinson's disease is being treated with carbidopa-levodopa. the daughter asks the nurse why he needs both agents. the nurse responds A. the two medications together are doubly effective B. this combination has fewer side effects C. you'll tolerate this better than a single agent medication D. the carbidopa helps the levodopa reach the brain

D

An expected patient problem for a patient admitted to the hospital with symptoms of diabetes insipidus is A. excess fluid volume related to intake greater than output. B. impaired gas exchange related to fluid retention in lungs. C. risk for impaired skin integrity related to generalized edema. D. sleep pattern disturbance related to frequent waking to void.

D (Patients with DI have significantly increase urine output. All other responses describe s/sx that would be expected with SIADH.)

The charge nurse on the endocrine surgical unit is making assignments. Which task should be delegated to the team members? A. Request the LPN assess the client who is hypoglycemic. B. Ask the UAP to assist feeding the client with an adrenalectomy who has a paralytic ileus C. Instruct the UAP to insert an NG tube into the client who had a thyroidectomy. D. Have the LPN perform a straight catheterization for the client with acromegaly.

D (Pt stable; appropriate task for LPN level training) Incorrect responses: A: don't delegate "assessment" to LPNs or UAPs/CNAs (means data collection and interpretation) B: don't feed a patient with a paralytic ileus (if you are unsure of what the term means as may happen with terms on your NCLEX, try to break it down: paralytic is like "paralyze"...."ileus" sounds like ileum, part of the small intestines; this patient's intestines are not functioning C: not an appropriate task for a UAP, particularly in a patient who has had a surgery near the airway/near where this tube will pass on its way into the stomach. )

What characteristic is related to Hashimoto's Thyroiditis? A. Enlarged thyroid glands B. Viral-Induced Hyperthyroidism C. Bacterial of Fungal infection of the Thyroid Gland D. Chronic Autoimmune Thyroiditis with antibody destruction of Thyroid Tissue

D (A=goiter, B=subacute thyroiditis, C= acute thyroiditis)

Hormone that increases in response to stress. Enhances and prolongs effects of sympathetic nervous system.

Epinephrine

The nurse provides care for a client who was placed in a halo brace within the last 24 hours because of a spinal cord injury. Which of the following is the first priority of the nurse?

Examine the pin sites. The nurse would want to observe pin sites for redness, edema, and drainage, and would want to assure that the vest fits snugly. Following the nursing process, data collection would precede implementation of the actions in the other choices.

True or False: Emergency treatment of tetany after surgery requires the administration of IV potassium

F (administer IV CALCIUM)

True or False: Addisonian crisis is a life-threatening emergency requiring aggressive management. Treatment is directed toward shock management and low-dose hydrocortisone replacement.

F (treat w/ shock management & HIGH-dose hydrocortisone replacement)

Hormone that promotes protein anabolism (growth, tissue repair) and lipid mobilization and catabolism.

Growth Hormone (GH)

The nurse tries education a patient on the use of Sumatriptan succinate STAT dose pen for self injection. The prescode dose is 4mg, which is the unit dose strength of the pen. Which statement , if made by the patient, indicates a need for nurse teaching about proposed use of the drug.

If after two 4mg injections, I do not experience the beginning of symptom relief, I should give myself a third 4mg injection.

A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority?

Imbalanced nutrition: less than body requirements

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. Which client activity suggests that teaching is most effective?

Taking medications on time to maintain therapeutic blood levels

A client with a history of myasthenic gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenia crisis is suspected. The nurse assesses the client for which precipitating factor?

Omitting doses of medication

Hormone that regulates calcium and phosphorus serum levels. Promotes bone demineralization and increases intestinal absorption of calcium. Increases serum calcium levels.

Parathyroid Hormone (PTH)

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

Positioning the patient's left leg when turning the patient

Jane, a 20- year old college student is admitted to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

Rapid but brief symptomatic improvement

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention?

Red skin areas under the jacket

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse avoid when planning care for this client?

Removing the weights to reposition the client

The nurse is reviewing a care plan for an assigned client diagnosed with paranoid schizophrenia. Which should be a priority diagnosis for this client?

Risk for other-directed violence

True or False: Hypothyroidism is a slowing of the metabolic rate.

T

True or False: The most common cause of Cushing's Syndrome is administration of exogenous corticosteroids such as prednisone.

T

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome?

The immune system destroys the myelin sheath.

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and BP of 162/96. The client reports a severe headache. Which of the following nursing interventions would be appropriate for this client? SATA a. elevate the head of bed to 90 degrees b. loosen constrictive clothing c. use a fan to reduce diaphoresis d. assess for bladder distention and bowel impaction e. administer antihypertensive medication f. place the client in a supine position with legs elevated

a, b, d, e

Brown-Sequard Syndrome is characterized by: choose two a. motor loss on the same side as the injury b. motor loss on the opposite side as the injury c. sensory loss on the same side as the injury d. sensory loss on the opposite side as the injury

a, d

The nurse is caring for a client with a spinal cord injury who has very little interest in eating or drinking. The nurse plans to instruct the client about risks associated with inadequate intake of food and fluids including which of the following? a. Skin breakdown b. Headaches c. Diarrhea d. Contractures of the legs

a. The client who is taking in inadequate food is at risk for developing breaks in the skin and resulting infection. Headaches and contractures are not associated with poor nutrition. Constipation, not diarrhea, is a risk associated with decreased fluids.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a. headache b. infection c. aphasia d. hypertension

b. infection is a complication. Strict asepsis should be used to avoid this life-threatening condition, which may result in meningitis. All others should be monitored, but not the priority.

Anterior Cord Syndrome is characterized by: a. complete loss of positional sense below the level of injury b. complete loss of motor function below the level of injury c. variable loss of motor and sensory level and maintenance of positional sense below the level of injury d. a complete disruption of all spinal tissue below the level of injury

c

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

d. using the ACB priority-setting, the greatest risk to the client is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention

Anterior Cord Syndrome is characterized by:

variable loss of motor and sensory level and maintenance of positional sense below the level of injury