NUR 405 Final Exam practice questions with correct
answers
In assessing a client with a Thoracic SCI, which clinical manifestation
would the nurse expect to find to support the diagnosis of neurogenic
shock?
A. No reflex activity below the waist.
B. Inability to move upper extremities.
C. Complaints of a pounding headache.
D. Hypertension and tachycardia. Correct Answer-A. No reflex activity
below the waist.
Rationale:
Neurogenic shock associated with SCI represents a sudden depression of
reflex activity below the level of the injury.TI2 is just above the waist;
therefore, no reflex activity below the waist would be expected.
TEST TAKING HINT: If the test taker does not have any idea what the
answer is, an attempt to relate the anatomical position of keywords in the
question stem to words in the answer options is appropriate. In this case,
T12, mentioned in the stem, is around the waist, so answer options
involving the anatomy above that level (e.g., the upper extremities) can
be eliminated.
,The nurse in the neurointensive care unit is caring for a client with a new
Cervical SCI who is breathing independently. Which nursing
interventions should be implemented? Select all that apply.
A. Monitor the pulse oximetry reading.
B. Provide pureed foods six (6) times a day.
C. Encourage coughing and deep breathing.
D. Assess for autonomic dysreflexia.
E. Administer intravenous corticosteroids. Correct Answer-A. Monitor
the pulse oximetry reading.
C. Encourage coughing and deep breathing.
E. Administer intravenous corticosteroids.
Rationale:
A) Oxygen is administered initially to prevent hypoxemia, which can
worsen the spinal cord injury; therefore, the nurse should determine how
much oxygen is reaching the periphery.
B) A C6 injury would not affect the client's ability to chew and swallow,
so pureed food is not necessary.
C) Breathing exercises are supervised by the nurse to increase the
strength and endurance of inspiratory muscles, especially those of the
diaphragm.
D) Autonomic dysreflexia occurs during the rehabilitation phase, not the
acute phase.
,E) Corticosteroids are administered to decrease inflammation, which
will decrease edema, and help prevent edema from ascending up the
spinal cord, causing breathing difficulties.
TEST TAKING HINT: The test taker must notice where the client is
receiving care, which may be instrumental in being able to rule out
incorrect answer options and help in identifying the correct answer.
Remember Maslow's hierarchy of needs- oxygen and breathing are
priority nursing interventions.
The client with a C6 SCI is admitted to the emergency department
complaining of a severe pounding headache and has a BP of 180/110.
Which intervention should the emergency department nurse implement?
A. Keep the client flat in bed.
B. Dim the lights in the room.
C. Assess for bladder distention.
D. Administer a narcotic analgesic. Correct Answer-C. Assess for
bladder distention.
Rationale:
This is an acute emergency caused by exaggerated autonomic responses
to stimuli and only occurs after spinal shock has resolved in the client
with a spinal cord injury above T6. The most common cause is a full
bladder.
, TEST TAKING HINT: The test taker should apply the nursing process
when answering questions, and assessing the client comes first, before
administering any type of medication.
The 34-year-old male client with an SCI is sharing with the nurse that he
is worried about finding employment after being discharged from the
rehabilitation unit. Which intervention should the nurse implement?
A. Refer the client to the American Spinal Cord Injury Association
(ASIA).
B. Refer the client to the state rehabilitation commission.
C. Ask the social worker (SW) about applying for disability.
D. Suggest that the client talk with his significant other about this
concern. Correct Answer-B. Refer the client to the state rehabilitation
commission.
Rationale:
The rehabilitation commission of each state will help evaluate and
determine if the client can receive training or education for another
occupation after injury.
TEST TAKING HINT: If the question mentions a specific age for a
client, the nurse should consider it when attempting to answer the
question. This is a young person who needs to find gainful employment.
Remember Erickson's stages of growth and development.
answers
In assessing a client with a Thoracic SCI, which clinical manifestation
would the nurse expect to find to support the diagnosis of neurogenic
shock?
A. No reflex activity below the waist.
B. Inability to move upper extremities.
C. Complaints of a pounding headache.
D. Hypertension and tachycardia. Correct Answer-A. No reflex activity
below the waist.
Rationale:
Neurogenic shock associated with SCI represents a sudden depression of
reflex activity below the level of the injury.TI2 is just above the waist;
therefore, no reflex activity below the waist would be expected.
TEST TAKING HINT: If the test taker does not have any idea what the
answer is, an attempt to relate the anatomical position of keywords in the
question stem to words in the answer options is appropriate. In this case,
T12, mentioned in the stem, is around the waist, so answer options
involving the anatomy above that level (e.g., the upper extremities) can
be eliminated.
,The nurse in the neurointensive care unit is caring for a client with a new
Cervical SCI who is breathing independently. Which nursing
interventions should be implemented? Select all that apply.
A. Monitor the pulse oximetry reading.
B. Provide pureed foods six (6) times a day.
C. Encourage coughing and deep breathing.
D. Assess for autonomic dysreflexia.
E. Administer intravenous corticosteroids. Correct Answer-A. Monitor
the pulse oximetry reading.
C. Encourage coughing and deep breathing.
E. Administer intravenous corticosteroids.
Rationale:
A) Oxygen is administered initially to prevent hypoxemia, which can
worsen the spinal cord injury; therefore, the nurse should determine how
much oxygen is reaching the periphery.
B) A C6 injury would not affect the client's ability to chew and swallow,
so pureed food is not necessary.
C) Breathing exercises are supervised by the nurse to increase the
strength and endurance of inspiratory muscles, especially those of the
diaphragm.
D) Autonomic dysreflexia occurs during the rehabilitation phase, not the
acute phase.
,E) Corticosteroids are administered to decrease inflammation, which
will decrease edema, and help prevent edema from ascending up the
spinal cord, causing breathing difficulties.
TEST TAKING HINT: The test taker must notice where the client is
receiving care, which may be instrumental in being able to rule out
incorrect answer options and help in identifying the correct answer.
Remember Maslow's hierarchy of needs- oxygen and breathing are
priority nursing interventions.
The client with a C6 SCI is admitted to the emergency department
complaining of a severe pounding headache and has a BP of 180/110.
Which intervention should the emergency department nurse implement?
A. Keep the client flat in bed.
B. Dim the lights in the room.
C. Assess for bladder distention.
D. Administer a narcotic analgesic. Correct Answer-C. Assess for
bladder distention.
Rationale:
This is an acute emergency caused by exaggerated autonomic responses
to stimuli and only occurs after spinal shock has resolved in the client
with a spinal cord injury above T6. The most common cause is a full
bladder.
, TEST TAKING HINT: The test taker should apply the nursing process
when answering questions, and assessing the client comes first, before
administering any type of medication.
The 34-year-old male client with an SCI is sharing with the nurse that he
is worried about finding employment after being discharged from the
rehabilitation unit. Which intervention should the nurse implement?
A. Refer the client to the American Spinal Cord Injury Association
(ASIA).
B. Refer the client to the state rehabilitation commission.
C. Ask the social worker (SW) about applying for disability.
D. Suggest that the client talk with his significant other about this
concern. Correct Answer-B. Refer the client to the state rehabilitation
commission.
Rationale:
The rehabilitation commission of each state will help evaluate and
determine if the client can receive training or education for another
occupation after injury.
TEST TAKING HINT: If the question mentions a specific age for a
client, the nurse should consider it when attempting to answer the
question. This is a young person who needs to find gainful employment.
Remember Erickson's stages of growth and development.
