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NURSING 138 EXAM QUESTIONS WITH COMPLETE SOLUTIONS

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NURSING 138 EXAM QUESTIONS
WITH COMPLETE SOLUTIONS

21 on stroke scale Correct Answers severe

A 79-year-old male client has been transferred to the emergency
department from a skilled nursing facility because of changes in
orientation and level of consciousness due to a fall. The nurse
records the most current set of vital signs as listed below:
Correct Answers administer bolus of saline
Draw blood for a complete blood count (CBC).
Check the client's blood glucose level.
Prepare to intubate the client.
Check pupil size and responsiveness.
Assess and record the client's LOC.

A client has a neurological deficit involving the limbic system.
On assessment, which finding is specific to this type of deficit?
Correct Answers Affect is flat, with periods of emotional
lability

A client with a cervical injury reports the sudden onset of a
severe headache and nasal congestion. For which clinical
manifestations would the nurse assess? Correct Answers
suprapubic distension

A client with a neurological problem is experiencing
hyperthermia. Which measures would be appropriate for the
nurse to use in trying to lower the client's body temperature?
Select all that apply. Correct Answers tepid sponge bath

, tylenol
fan
hypothermia (cooling) blanket

A client with a spinal cord injury at the level of C5 has a
weakened respiratory effort and ineffective cough and is using
accessory neck muscles in breathing. The nurse carefully
monitors the client and suspects the presence of which problem?
Correct Answers altered breathing pattern

A client with a spinal cord injury is prone to experiencing
autonomic dysreflexia. The nurse should include which
measures in the plan of care to minimize the risk of occurrence?
Select all that apply. Correct Answers wrinkle-free linens
preventing pressure
repositioning

A male client with a brain attack (cerebrovascular accident) is
incontinent of urine. Which action would the nurse encourage to
help the client reestablish bladder control? Correct Answers
Assume a standing position when voiding

A nurse assesses a patient who experienced a spinal cord injury
at the T5 level 12 hours ago. Which manifestations would the
nurse correlate with neurogenic shock? (Select all that apply.)
Correct Answers HR 34
urine output <30
decreased LOC

A nurse evaluates the results of diagnostic tests on a client's
cerebrospinal fluid (CSF). Which fluid results alert the nurse to

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