ATI MEDSURG 2 NUR 265/ DETAILED
ANSWER KEY NEURO- SHOCK & BURNS
PRACTICE QUESTIONS & ANSWERS 202
4
1.A nurse in the emergency department is implementing a plan of care f
or a conscious client who has a suspected cervical cord injury. Which o
f the following immediate interventions should the nurse implement? (S
elect all that apply.)
A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex
Rationale: <b>Hypotension is correct.</b> Lack of sympathetic inp
ut can cause a decrease in blood pressure. The nurse shoul
d maintain the client's SBP at 90 mm Hg or above to adequ
ately perfuse the spinal cord.</br></br><b>Polyuria is incorr
ect.</b> The nurse should check the client for bladder diste
ntion and inability to urinate due to ineffective function of the
bladder muscles.</br></br><b>Hyperthermia is incorrect.</
b> The nurse should monitor the client for hypothermia caus
ed by a lack of lack of sympathetic input.</br></br><b>Abse
nce of bowel sounds is correct.</b> Spinal shock leads to d
ecreased peristalsis, which could cause the client to develo
Page
, p a paralytic ileus.</br></br><b>Weakened gag reflex is cor
rect.</b> The nurse should monitor the client for difficulty sw
allowing, 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. Which of the following statement
s 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 phenytoi
n; therefore, the client's provider should be notified 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 over
growth of the gums that makes dental monitoring important.
C. "I know that I cannot switch brands of this medication."
Rationale: The client understands that bioavailability varies with d
ifferent brands, so no substitutions should be made.
D. "I'll be glad when I can stop taking this medicine."
Rationale: Phenytoin is an anticonvulsant used to treat various ty
pes of seizures. Clients on anticonvulsant medications com
monly require them for lifetime administration, and phenyto
in should not be stopped without the advice of the client's p
rovider.
3.A nurse at an ophthalmology clinic is providing teaching to a client who h
as open angle glaucoma and a new
Page
,prescription for timolol eye drops. Which of the following instructions s
hould 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 reduc
e intraocular pressure and preserve remaining eyesight.
B. The medication will be used until the client's intraocular pressure r
eturns to normal.
Rationale: Treatment for open-angle glaucoma is to continue for l
ife. Abrupt discontinuation can worsen the client's condition.
C. The medication should be applied on a regular schedule for the re
st of the client's life.
Rationale: Medications prescribed for open angle glaucoma are i
ntended to enhance aqueous outflow, or decrease its prod
uction, or both. The client must continue the eye drops on
an uninterrupted basis for life to maintain intraocular press
ure at an acceptable level.
D. The medication is to be used for approximately 10 days, followed b
y a gradual tapering off.
Rationale: Treatment for open-angle glaucoma is to continue for l
ife.
4.A nurse is in a client's room when the client begins having a tonic-
clonic seizure. Which of the following actions should the nurse take
first? A. Turn the client's head to the side.
Page
, Rationale: The first action the nurse should take when using the
airway, breathing, circulation approach to client care is to turn the clie
nt's head to the side. This action keeps the client's airway clear of sec
retion to prevent aspiration. B. Check the client's motor strength.
Rationale: The nurse should check the client's motor strength as par
t of a neurovascular assessment following the seizure; howev
er, 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 clie
nt'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 bega
n and ended to provide information to the provider about th
e severity of the seizure; however, there is another action t
he nurse should take first.
5.A nurse is caring for a client following cataract surgery. Which of the fo
llowing comments from the client should the nurse report to the client's
provider?
A. "My eye really itches, but I'm trying not to
rub it." Rationale: Itching is common
after cataract surgery. The nurse
should remind the client not to rub or
place pressure on the eyes
Page
ANSWER KEY NEURO- SHOCK & BURNS
PRACTICE QUESTIONS & ANSWERS 202
4
1.A nurse in the emergency department is implementing a plan of care f
or a conscious client who has a suspected cervical cord injury. Which o
f the following immediate interventions should the nurse implement? (S
elect all that apply.)
A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex
Rationale: <b>Hypotension is correct.</b> Lack of sympathetic inp
ut can cause a decrease in blood pressure. The nurse shoul
d maintain the client's SBP at 90 mm Hg or above to adequ
ately perfuse the spinal cord.</br></br><b>Polyuria is incorr
ect.</b> The nurse should check the client for bladder diste
ntion and inability to urinate due to ineffective function of the
bladder muscles.</br></br><b>Hyperthermia is incorrect.</
b> The nurse should monitor the client for hypothermia caus
ed by a lack of lack of sympathetic input.</br></br><b>Abse
nce of bowel sounds is correct.</b> Spinal shock leads to d
ecreased peristalsis, which could cause the client to develo
Page
, p a paralytic ileus.</br></br><b>Weakened gag reflex is cor
rect.</b> The nurse should monitor the client for difficulty sw
allowing, 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. Which of the following statement
s 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 phenytoi
n; therefore, the client's provider should be notified 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 over
growth of the gums that makes dental monitoring important.
C. "I know that I cannot switch brands of this medication."
Rationale: The client understands that bioavailability varies with d
ifferent brands, so no substitutions should be made.
D. "I'll be glad when I can stop taking this medicine."
Rationale: Phenytoin is an anticonvulsant used to treat various ty
pes of seizures. Clients on anticonvulsant medications com
monly require them for lifetime administration, and phenyto
in should not be stopped without the advice of the client's p
rovider.
3.A nurse at an ophthalmology clinic is providing teaching to a client who h
as open angle glaucoma and a new
Page
,prescription for timolol eye drops. Which of the following instructions s
hould 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 reduc
e intraocular pressure and preserve remaining eyesight.
B. The medication will be used until the client's intraocular pressure r
eturns to normal.
Rationale: Treatment for open-angle glaucoma is to continue for l
ife. Abrupt discontinuation can worsen the client's condition.
C. The medication should be applied on a regular schedule for the re
st of the client's life.
Rationale: Medications prescribed for open angle glaucoma are i
ntended to enhance aqueous outflow, or decrease its prod
uction, or both. The client must continue the eye drops on
an uninterrupted basis for life to maintain intraocular press
ure at an acceptable level.
D. The medication is to be used for approximately 10 days, followed b
y a gradual tapering off.
Rationale: Treatment for open-angle glaucoma is to continue for l
ife.
4.A nurse is in a client's room when the client begins having a tonic-
clonic seizure. Which of the following actions should the nurse take
first? A. Turn the client's head to the side.
Page
, Rationale: The first action the nurse should take when using the
airway, breathing, circulation approach to client care is to turn the clie
nt's head to the side. This action keeps the client's airway clear of sec
retion to prevent aspiration. B. Check the client's motor strength.
Rationale: The nurse should check the client's motor strength as par
t of a neurovascular assessment following the seizure; howev
er, 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 clie
nt'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 bega
n and ended to provide information to the provider about th
e severity of the seizure; however, there is another action t
he nurse should take first.
5.A nurse is caring for a client following cataract surgery. Which of the fo
llowing comments from the client should the nurse report to the client's
provider?
A. "My eye really itches, but I'm trying not to
rub it." Rationale: Itching is common
after cataract surgery. The nurse
should remind the client not to rub or
place pressure on the eyes
Page
