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NUR 402 EXAM 4 NCLEX 90 QUESTIONS AND ANSWERS VERIFIED GUARANTEED PASS ALREADY GRADED A 2023/202
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NUR 402 EXAM 4 NCLEX 90 QUESTIONS AND ANSWERS VERIFIED GUARANTEED PASS ALREADY GRADED A 2023/202
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NUR 402 EXAM 4 NCLEX 90 QUESTIONS AND ANSWERS VERIFIED GUARANTEED PASS ALREADY GRADED A 2023/2024 A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with Brown -Séquard syndrome. On physical examination, the nurse would most likely find A) upper extremity weakness only. B) comple te motor and sensory loss below C7. C) loss of position sense and vibration in both lower extremities. D) ipsilateral motor loss and contralateral sensory loss below C7. D) ipsilateral motor loss and contralateral sensory loss below C7. Brown -Séquard synd rome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function, position sense, and vibratory sense, as well as by vasomotor paralysis on the same side (ipsilateral) as the injury. The opposite (contra lateral) side has loss of pain and temperature sensation below the level of the injury. A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 84/50 mm Hg, his pulse is 38 beats/minute, and he r emains orally intubated. The nurse determines that this pathophysiologic response is caused by A) increased vasomotor tone after injury. B) a temporary loss of sensation and flaccid paralysis below the level of injury. C) loss of parasympathetic nervous sy stem innervation resulting in vasoconstriction. D) loss of sympathetic nervous system innervation resulting in peripheral vasodilation. D) loss of sympathetic nervous system innervation resulting in peripheral vasodilation. Neurogenic shock results from l oss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associate d with a cervical or high thoracic injury (T6 or higher). Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) A) stand erect with leg brace. B) feed self with hand devices. C) assist with transfer activiti es. D) drive adapted van from wheelchair. E) push a wheelchair on a flat surface. B) feed self with hand devices. C) assist with transfer activities. D) drive adapted van from wheelchair. E) push a wheelchair on a flat surface. Rehabilitation goals for a patient with a spinal cord injury at the C6 level include the ability to assist with transfer and perform some self -care; feed self with hand devices; push a wheelchair on smooth, flat surfaces; drive an adapted van from a wheelchair; independent computer use with adaptive equipment; and need for attendant care for only 6 hours per day. A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to A) call the physician. B) check the patient's temperature. C) take the patient's blood pressure. D) elevate the head of the bed to 90 degrees. C) take the patient's blood pressure. Autonomic dysreflexia is a massive, uncompensated cardiovascular react ion mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the injury, bradycardia (30 to 40 beats/min), piloerection, flushing of the skin above the level of the injury, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of headache. Other nursing interventions in this ser ious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. Table 61-8 lists the causes and symptoms of autonomic dysreflexia. The nurse must monitor b lood pressure frequently during the episode. An α -adrenergic blocker or an arteriolar vasodilator may be administered. For a 65 -year-old woman who has lived with a T1 spinal cord injury for 20 years, which health teaching instructions should the nurse emph asize? A) A mammogram is needed every year. B) Bladder function tends to improve with age. C) Heart disease is not common in persons with spinal cord injury. D) As a person ages, the need to change body position is less important. A) A mammogram is needed every year. Health promotion and screening are important for an older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and undergo yearly mammography. The most common early symptom o f a spinal cord tumor is A) urinary incontinence. B) back pain that worsens with activity. C) paralysis below the level of involvement. D) impaired sensation of pain, temperature, and light touch. B) back pain that worsens with activity. The most common early symptom of a spinal cord tumor outside the cord is pain in the back, with radicular pain simulating intercostal neuralgia, angina, or herpes zoster. The location of the pain depends on the level of compression. The pain worsens with a ctivity, coughing, straining, and lying down. The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which abnormality associated with this oncologic emergency? A) Hypokalemia B) Hypouricemia C) Hypocalcemia D) Hypophosphatemia C) Hypocalcemia TLS is a metabolic complication characterized by rapid re lease of intracellular components in response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia. The nurse is caring for a patient suffering from ano rexia secondary to chemotherapy. Which strategy would be most appropriate for the nurse to use to increase the patient's nutritional intake? A) Increase intake of liquids at mealtime to stimulate the appetite. B) Serve three large meals per day plus snacks between each meal. C) Avoid the use of liquid protein supplements to encourage eating at mealtime. D) Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods. D) Add items such as skim milk powder, cheese, honey, or peanut bu tter to selected foods. The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be helpful. Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? A) Firm -bristle toothbrush B) Hydrogen peroxide rinse C) Alcohol -based mouthwash D) 1 tsp salt in 1 L water mouth rinseThe benefits of buying summaries with Stuvia:
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