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Neuro-Shock & Burns practice test_Latest Detailed Answer Keywritten bydennyswww.stuvia.com
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1.A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspectedcervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all thatapply.)
A. HypotensionB. PolyuriaC. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflexRationale:<b>Hypotension is correct.</b> Lack of sympathetic input can cause a decrease in bloodpressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequatelyperfuse the spinal cord.</br></br><b>Polyuria is incorrect.</b> The nurse should check theclient for bladder distention and inability to urinate due to ineffective function of the bladdermuscles.</br></br><b>Hyperthermia is incorrect.</b> The nurse should monitor the client forhypothermia caused by a lack of lack of sympathetic input.</br></br><b>Absence of bowelsounds is correct.</b> Spinal shock leads to decreased peristalsis, which could cause the clientto develop a paralytic ileus.</br></br><b>Weakened gag reflex is correct.</b> The nurse shouldmonitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.2.A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Whichof the following statements by the client indicates a need for further teaching?A. "I will notify my doctor before taking any other medications."Rationale:Many medication interactions can occur with phenytoin; therefore, the client's provider should benotified that the client is taking phenytoin.B. "I have made an appointment to see my dentist next week."Rationale:The client understands that phenytoin causes an overgrowth of the gums that makes dentalmonitoring important.C. "I know that I cannot switch brands of this medication."Rationale:The client understands that bioavailability varies with different brands, so no substitutions shouldbe made.
D. "I'll be glad when I can stop taking this medicine."Rationale:Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsantmedications commonly require them for lifetime administration, and phenytoin should not bestopped without the advice of the client's provider.3.A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a newCreated on:11/26/2018Page 1Stuvia.com - The Marketplace to Buy and Sell your Study Material
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Detailed Answer KeyNeuro-Shock & Burns practice
prescription for timolol eye drops. Which of the following instructions should the nurse provide?A. The medication is to be applied when the client is experiencing eye pain.Rationale:The client needs to take the medications daily to reduce intraocular pressure and preserveremaining eyesight.B. The medication will be used until the client's intraocular pressure returns to normal.Rationale:Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen theclient's condition.
C. The medication should be applied on a regular schedule for the rest of the client's life.Rationale:Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, ordecrease its production, or both. The client must continue the eye drops on an uninterruptedbasis for life to maintain intraocular pressure at an acceptable level.D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.Rationale:Treatment for open-angle glaucoma is to continue for life.4.A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actionsshould the nurse take first?
A. Turn the client's head to the side.Rationale:The first action the nurse should take when using the airway, breathing, circulation approach toclient care is to turn the client's head to the side. This action keeps the client's airway clear ofsecretion to prevent aspiration.B. Check the client's motor strength.Rationale:The nurse should check the client's motor strength as part of a neurovascular assessmentfollowing the seizure; however, there is another action the nurse should take first.C. Loosen the clothing around the client's waist.Rationale:The nurse should loosen the clothing around the client's waist to protect the client from injury;however, there is another action the nurse should take first.D. Document the time the seizure began.Rationale:The nurse should document the time the seizure began and ended to provide information to theprovider about the severity of the seizure; however, there is another action the nurse should takefirst.5.A nurse is caring for a client following cataract surgery. Which of the following comments from the client should thenurse report to the client's provider?A. "My eye really itches, but I'm trying not to rub it."Rationale:Created on:11/26/2018Page 2Stuvia.com - The Marketplace to Buy and Sell your Study Material
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Detailed Answer KeyNeuro-Shock & Burns practice
Itching is common after cataract surgery. The nurse should remind the client not to rub or placepressure on the eyes.
B. "I need something for the pain in my eye. I can't stand it."Rationale:Following cataract surgery, the client should expect only mild pain and should immediatelyreport any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain aftersurgery might indicate increased intraocular pressure or hemorrhage.C. "It's hard to see with a patch on one eye. I'm afraid of falling."Rationale:Clients who wear an eye patch lose their depth perception and part of their peripheral vision,temporarily decreasing visual acuity.D. "The bright light in this room is really bothering me."Rationale:The client may find that exposure to bright light is uncomfortable after cataract surgery. Wearingsunglasses can prevent most of the client's discomfort.6.A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. Whileassessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of thefollowing should be the nurse’s initial action?A. Document the amount of drainage.Rationale:The nurse should document the amount of drainage along with the clarity to determine theextent of the cerebral spinal fluid (CSF) leakage and the presence of blood or pus; howeverthere is another action that is priority.B. Obtain a culture of the drainage.Rationale:Although infection is a potential complication of the procedure, there is another action that ispriority.
C. Check the drainage for glucose.Rationale:A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakagefrom the nose is a sign that this complication has occurred. The first action the nurse should takeusing the nursing process is to assess the drainage for the presence of glucose, which wouldindicate that the drainage is CSF.D. Notify the client's provider.Rationale:Although the provider should be notified of the findings, there is another action that is priority.7.A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of thefollowing parameters should the nurse use first in order to assess the client's pain level?A. pulse and blood pressure findingsRationale:The nurse should assess the client's pain level routinely along with vital signs. A painCreated on:11/26/2018Page 3Stuvia.com - The Marketplace to Buy and Sell your Study Material
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