Exam (elaborations)
N308 Exam 3 Evolve Questions with correct answers
- Course
- Nurs 308
- Institution
- Liberty University
N308 Exam 3 Evolve Questions with correct answers
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N308 Exam 3 Evolve Questions with correct answersThe nurse is caring for a 63-yr-old woman taking prednisone
(Deltasone) for Bell's palsy. Which statement by the patient requires
correction by the nurse?
"I can take the medication with food or milk."
"The medication should be started 1 week after paralysis."
"I can take acetaminophen with the prescribed medications."
Chances of a full recovery are good if I take the medication" Correct
Answer-"The medication should be started 1 week after paralysis."
Rationale: Prednisone should be started immediately. Patients have the
best chance for full recovery if prednisone is initiated before complete
paralysis occurs. Prednisone will be tapered over the last 2 weeks of
treatment. Oral prednisone may be taken with food or milk to decrease
gastrointestinal upset. Patients with Bell's palsy usually begin recovery
in 2 to 3 weeks, and most patients have complete recovery in 3 to 6
months. No serious drug interactions occur between prednisone and
acetaminophen
The nurse is caring for a patient with a halo vest after cervical spine
injury. Which care instructions should the nurse include in the patient's
discharge plan?
Keep a wrench close or attached to the vest.
Use the frame and vest to assist in positioning.
,Clean around the pins using betadine swab sticks
Loosen both sides of the vest to provide skin care. Correct Answer-Keep
a wrench close or attached to the vest.
A halo vest is used to provide cervical spine immobilization while
vertebrae heal. A wrench should accompany the halo vest at all times in
case emergency removal of the vest is needed (e.g., performance of
CPR). Cleaning around the pins is typically performed with half strength
hydrogen peroxide, normal saline, or chlorhexidine, based on provider
instructions. Only one side of the vest can be loosened for skin care and
changing clothes. After that side has been reattached, the other side of
the vest can be loosened.
The nurse performs discharge teaching for a 34-yr-old male patient with
a thoracic spinal cord injury (T2) from a construction accident. Which
patient statement indicates teaching about autonomic dysreflexia is
successful?
"I will perform self-catheterization at least six times per day."
"A reflex erection may cause an unsafe drop in blood pressure."
"If I develop a severe headache, I will lie down for 15 to 20 minutes."
"I can avoid this problem by taking medications to prevent leg spasms."
Correct Answer-"I will perform self-catheterization at least six times per
day."
Autonomic dysreflexia usually is caused by a distended bladder.
Performing self-catheterization five or six times a day prevents bladder
,distention. Signs and symptoms of autonomic dysreflexia include a
severe headache, hypertension, bradycardia, flushing, piloerection
(goosebumps), and nasal congestion. Patients should raise the head of
the bed to 45 to 90 degrees. This action helps to relieve hypertension
(systolic pressure up to 300 mm Hg) that occurs with autonomic
dysreflexia.
A 22-yr-old woman with paraplegia after a spinal cord injury tells the
home care nurse she experiences bowel incontinence two or three times
each day. Which action by the nurse is most appropriate?
Insert a rectal stimulant suppository.
Teach the patient to gradually increase intake of high-fiber foods.
Assess bowel movements for frequency, consistency, and volume.
Instruct the patient to avoid all caffeinated and carbonated beverages.
Correct Answer-Assess bowel movements for frequency, consistency,
and volume.
The nurse should establish baseline bowel function and explore the
patient's current knowledge of an appropriate bowel management
program after spinal cord injury. To prevent constipation, caffeine intake
should be limited but need not be eliminated. After stabilization,
creation of a bowel program including a rectal stimulant, digital
stimulation, or manual evacuation at the same time each day will
regulate bowel elimination. Instruction on high-fiber foods is indicated if
the patient has a knowledge deficit.
, The nurse is caring for a patient admitted with a spinal cord injury after
a motor vehicle accident. The patient exhibits a complete loss of motor,
sensory, and reflex activity below the injury level. The nurse recognizes
this condition as which of the following?
Central cord syndrome
Spinal shock syndrome
Anterior cord syndrome
Brown-Séquard syndrome Correct Answer-Spinal shock syndrome
About 50% of people with acute spinal cord injury experience spinal
shock, a temporary loss of reflexes, sensation, and motor activity.
Central cord syndrome is manifested by motor and sensory loss greater
in the upper extremities than the lower extremities. Anterior cord
syndrome results in motor and sensory loss but not loss of reflexes.
Brown-Séquard syndrome is characterized by ipsilateral loss of motor
function and contralateral loss of sensory function.
Which clinical manifestation would the nurse interpret as a
manifestation of neurogenic shock in a patient with acute spinal cord
injury?
Bradycardia
Hypertension
Neurogenic spasticity
Bounding pedal pulses Correct Answer-Bradycardia
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