Nokea
A 28-year-old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but cannot move the right. However, she cannot feel any pain in her left. The nurse knows these symptoms suggest which type of spinal cord injury?
- A. Incomplete spinal cord injury, central cord syndrome
- B. Incomplete spinal cord injury, Brown-Sequard syndrome
- C. Complete spinal cord injury, paraplegia
- D. Incomplete spinal cord injury, anterior cord syndrome
Correct Answer: B
Rationale: Brown-Sequard syndrome involves ipsilateral motor loss and contralateral sensory loss.
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The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client's plan of care?
- A. Observe the client during meals
- B. Keep suction at the bedside
- C. Provide large print education materials
- D. Teach the client to scan the room
- E. Alternate the use of an eye patch
Correct Answer: A,B
Rationale: Hypoglossal nerve impairment affects tongue movement, increasing choking risk, necessitating meal observation and suction availability.
The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
- A. Client reports a decreased smell
- B. No bowel movement in two days
- C. Foul-smelling breath
- D. Hourly urine output of 125 mL
Correct Answer: D
Rationale: High urine output suggests diabetes insipidus, a serious complication post-hypophysectomy.
The nurse is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
- A. Abrupt onset
- B. Change in psychomotor activity
- C. Irreversible
- D. Progressively worsens
- E. Decreased attention and awareness
- F. Fluctuating level of consciousness
Correct Answer: A,B,E,F
Rationale: Delirium is characterized by abrupt onset, changes in psychomotor activity, decreased attention, and fluctuating consciousness. It is reversible, unlike dementia.
The nurse is caring for a client who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse?
- A. Administer prescribed carbamazepine
- B. Notify the rapid response team (RRT)
- C. Obtain a prescription for lorazepam
- D. Loosen any restrictive clothing
- E. Review the client's most recent phenytoin level
Correct Answer: B,C,D
Rationale: Status epilepticus is a medical emergency requiring immediate action. Notifying the RRT ensures rapid intervention, obtaining a lorazepam prescription is critical to stop seizures, and loosening restrictive clothing prevents injury and ensures airway patency.
In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia?
- A. Hypotension
- B. Sudden headache
- C. Flushed face
- D. Nasal congestion
- E. Profuse sweating above the level of the injury
Correct Answer: B,C,D,E
Rationale: Autonomic dysreflexia causes headache, flushing, nasal congestion, and sweating above the injury level due to sympathetic overactivity.