PCC III Exam 2 Practice Questions
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the ruse should anticipate which of the following types of disability? A. Paraplegia B. Parethesia C. Hemiplegia D. Quadriplegia
A
What is the function of a halo fixation?
A halo fixator is a device used for the immobilization of the cervical spine. The device is affixed by four pins into the outer aspect of the skull.
What health history question will give the nurse the most information when evaluating a patient for Guillain-Barre syndrome (GBS)?
Any recent untreated bacterial or viral infections?
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate what disability?
paraplegia
What are signs of intracranial pressure?
- changes in LOC - behavior changes - headache - nausea and vomiting - change in speech pattern or slurred speech - seizures - cushing's triad - abnormal posturing - dilated pupils, pinpoint pupils, or asymmetrical pupils
The nurse is caring for a patient who had a craniotomy. What interventions should the nurse use to prevent respiratory complications of atelectasis and pneumonia?
- possible mechanical ventilation for the first 48 hours - suctioning - turn the pt. frequently - deep breathing - incentive spirometry - chest physiotherapy
Name some abilities a patient with an injury at the level of C5 should set goals to do?
- regain control of the bladder and bowel through retraining - independent feeding - upper body ROM exercise - operate a motorized wheelchair - diaphragmatic breathing - grasp objects
Which symptoms indicate that a patient with a spinal cord injury is experiencing autonomic dysreflexia?
- sudden, significant rise in systolic and diastolic blood pressure with bradycardia - profuse sweating above the level of the lesion - goosebumps above or below the level of the lesion - flushing of the skin above the level of the lesion - blurred vision - spots in the patient's visual field - nasal congestion - onset of severe, throbbing headache - pale skin below the level of the lesion feelings of apprehension
How do you know if mannitol is working?
- urine output of at least 30 mL/hr - reduction of intracranial pressure
What are late signs of ICP?
- widened pulse pressure - severe hypertension - bradycardia
A nurse is teaching a client who has a spinal cord injury about a new prescription for baclofen. What instructions should the nurse include in the teaching?
- you can take baclofen with food - avoid concurrent use of alcohol or other CNS depressants - change positions slowly to avoid orthostatic hypotension avoid driving or other activities that require alertness due to drowsiness - do not abruptly stop the medication as this can lead to withdrawal - report signs and symptoms of hypersensitivity immediately
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and throw from the vehicle. When assessing the patient, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? A. Allow the drainage to drip onto a sterile gauze pad B. Obtain a culture of the specimen using sterile swabs C. Suction the nose gently with a bulb syringe D. I steer sterile packing into the nares
A
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with IV morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Which of the following actions should the nurse anticipate the neurosurgeon taking? A. Invoking implied consent B. Delaying the surgery until a member of the client's family arrives C. Asking the client to sign the surgical consent form D. Prescribing naloxone to reverse the effects of the morphine
A
A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor vehicle accident. Which of the following is an expected finding for this client? A. Alternating periods of alertness and unconsciousness B. Narrowing pulse pressure C. Drainage of clear fluid from the ears D. Extensive bruising in the mastoid area
A
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension
A
A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside? A. Bag valance mask device B. Defibrillator machine C. Chest tube equipment D. Central venous catheter tray
A
A nurse is caring for a client who has paraplegia following an automobile accident. The client is on intermittent urinary catheterization program. Which of the following indicates the need for catheterization? A. Dribbling of urine B. Urge incontinence C. Weight gain D. Rectal distention
A - dribbling of urine or overflow incontinence is an indication of bladder distention
A nurse is teaching a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client indicated a need for further teaching? A. I can take my morning dose of metformin B. I will keep my head still during the procedure C. I will not eat for 4 hours prior to the procedure D. I will feel a warm sensation when the dye is injected
A - withheld 48 hours prior to procedure
A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following should the nurse expect? (Select all that apply). A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex
A, D, E
a nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). which of the following findings indicates that the medication is having a therapeutic effect? A. the client's serum osmolarity is 310 mOsm/L B. the client's pupils are dilated C. the client's heart rate is 56/min D. the client is restless
A. the client's serum osmolarity is 310 mOsm/L explanation: mannitol is an osmotic diuretic used to reduce cerebral edema by draining water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP
What is the main sign that tells you intracranial pressure is increasing and cerebral perfusion is decreasing?
Altered LOC
You're educating a patient about treatment options for Guillian-Barré Syndrome. Which statement by the patient requires you to re-educate the patient about treatment? A. Treatments available for this syndrome do not cure the condition but helps speed up recovery time B. Plasmapheresis or immunoglobulin therapies are treatment options available for this syndrome but are most effective when given within 4 weeks of the onset of this syndrome C. When I start plasmapheresis treatment a machine will filter my blood to remove the antibodies from my plasma that are attacking the myelin sheath D. Immunoglobulin therapy is where IV immunoglobulin from a donor is given to a patient to stop the antibodies that are damaging the nerves
B - 2 weeks not 4
a nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 SCI. after checking the client's vital signs, which of the following actions should the nurse perform next? A. administer nifedipine B. place the client in a high-fowler's position C. check for urinary retention D. check for a fecal impaction
B. place the client in a high-fowler's position explanation: according to evidence-based practice, the nurse should first place the client in a high-fowler's position to decrease the client's BP and reduce the risk of end-organ damage from sudden rise in BP
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury B. A client with a herniated nucleus pulposus C. A client with a high cervical spine injury D. A client with a stroke
C
a nurse is assessing a client who has increased intracranial pressure (ICP) and has received intravenous mannitol. which of the following findings indicates a therapeutic effect of this medication? A. decreased blood glucose B. decreased bronchospasms C. increased urine output D. increased temperature
C. increased urine output explanation: mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting reabsorption of water and electrolytes in the kidneys. increased urine output and decreased intracranial pressure are therapeutic effects of this medication
a nurse is assessing a client who has a high-thoracic SCI. the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. flushing of the lower extremities B. hypotension C. tachycardia D. report of a headache
D. report of a headache explanation: autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic SCI above the level of T6. autonomic dysreflexia can be trigger by a full bladder or distended rectum. manifestations include a severe throbbing headache; flushing of the face & neck; bradycardia, and extreme hypertension
Know decorticate and decerebrate posturing and what does this mean?
Decorticate posturing is seen in the patient with lesions that interrupt the corticospinal pathways. Decerebrate posturing is associated with dysfunction of the brainstem; in patients with TBI or ICP, this can indicate oncoming brainstem herniation and death.
The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed?
Elevate the head of the bed 30 to 45 degrees to prevent aspiration. Maintain the head in midline, neutral position while avoiding extreme flexion or extension of the neck.
Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in patients with spinal cord injury T6 and above. The first priority of care is to do what?
Immediately raise the head of the bed to help reduce blood pressure.
