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NURS 309 Quiz 15 Questions With Complete Solutions
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NURS 309 Quiz 15 Questions With Complete Solutions
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NURS 309 Quiz 15 Questions With Complete SolutionsA client has a functional transection of the spinal cord at C7-8,
resulting in spinal shock. Which clinical indicators does the
nurse expect to identify when assessing the client immediately
after the injury? SATA
A. Spasticity
B. Incontinence
C. Flaccid paralysis
D. Respiratory failure
E. Lack of reflexes below the injury Correct Answers C.
Flaccid paralysis
E. Lack of reflexes below the injury
A client has paraplegia as a result of a motorcycle accident.
What is the reason the nursing care plan should include turning
the client every 1 to 2 hours?
A. Maintain comfort
B. Prevent pressure ulcers
C. Prevent flexion contractures of the extremities
D. Improve venous circulation in the lower extremities Correct
Answers B. Prevent pressure ulcers
A client is in the intensive care unit after sustaining a T2 spinal
cord injury. Which priority interventions should the nurse
include in the client's plan of care? SATA
A. Minimizing environmental stimuli
B. Assessing for respiratory complications
C. Monitoring and maintaining blood pressure
D. Initiating a bowel and bladder training program
,E. Discussing long-term treatment plans with the family Correct
Answers B. Assessing for respiratory complications
C. Monitoring and maintaining blood pressure
A client with a cervical spinal cord injury has been placed in a
fixed skeletal traction with a halo fixation device. When caring
for this client, the nurse may assign which actions to the
LPN/LVN? SATA
A. Checking the client's skin for pressure from the device
B. Assessing the client's neurologic status for changes
C. Observing the halo insertion sites for signs of infection
D. Cleaning the halo insertion sites with hydrogen peroxide
E. Developing the nursing plan of care for the client
F. Administering oral medications as ordered Correct Answers
A. Checking the client's skin for pressure from the device
C. Observing the halo insertion sites for signs of infection
D. Cleaning the halo insertion sites with hydrogen peroxide
F. Administering oral medications as ordered
A client with a spinal cord injury (SCI) reports sudden severe
throbbing headache that started a short time ago. Assessment of
the client reveals increased blood pressure (168/94 mm Hg) and
decreased heart rate (48 beats/min), diaphoresis, and flushing of
the face and neck. What action should the nurse take first?
A. Administer the ordered acetaminophen
B. Check the Foley tubing for kinks or obstruction
C. Adjust the temperature in the client's room
D. Notify the health care provider about the change in status
Correct Answers B. Check the Foley tubing for kinks or
obstruction
, A client with a spinal cord injury at level C3 to C4 is being
cared for by the nurse in the emergency department (ED). What
is the priority nursing assessment?
A. Determine the level at which the client has intact sensation
B. Assess the level at which the client has retained mobility
C. Check the blood pressure and pulse for signs of spinal shock
D. Monitor respiratory effort and oxygen saturation level
Correct Answers D. Monitor respiratory effort and oxygen
saturation level
A client with a spinal cord injury has paraplegia. The nurse
assesses for which major problem the client may experience
early in the recovery period?
A. Bladder control
B. Nutritional intake
C. Quadriceps setting
D. Use of aids for ambulation Correct Answers A. Bladder
control
A client with quadriplegia is placed on a tilt table daily. Each
day the angle of the head of the table gradually is increased.
What should the nurse identify as its purpose when the client
asks the reason for the tilt table?
A. Facilitates turning
B. Prevents pressure ulcers
C. Promotes hyperextension of the spine
D. Limits loss of calcium from the bones Correct Answers D.
Limits loss of calcium from the bones
A nurse finds a victim under the wreckage of a collapsed
building. The individual is conscious, supine, breathing
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