Nokea
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
- A. Sciatic nerve pain
- B. Herniation
- C. Paresthesia
- D. Paralysis
Correct Answer: C
Rationale: A client reports numbness and tingling in an area is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
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A 6-year-old child has come to the emergency department (ED) after falling off a bike. The health care provider diagnoses a concussion and the child's parent asks the nurse what a concussion is. What should the nurse's response be?
- A. A concussion is a blow to the head that bruises the brain.
- B. A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.
- C. A concussion is a blow to the head that is minor and has no real consequences.
- D. A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain.
Correct Answer: D
Rationale: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. The other options are incorrect because they give incorrect information to the mother.
The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful?
- A. Adoption is an option to complete your family but not put your life in jeopardy.
- B. Conception is not impaired, the birth process is determined with the health care provider.
- C. Birth via surrogate is best because your baby can be implanted in another woman.
- D. Sterilization is best; it would be difficult to care for a baby in your condition.
Correct Answer: B
Rationale: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.
The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious, stating, 'What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain?' The nurse is most correct to turn the teaching to which surgical procedure?
- A. A discectomy
- B. A laminectomy
- C. A spinal fusion
- D. Aggressive traction
Correct Answer: C
Rationale: The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the vertebrae weakened by degenerative joint changes such as osteoarthritis and by a laminectomy. A discectomy provides pain relief by the removal of a ruptured disk. A laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord. From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc. Aggressive traction is not a surgical option.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
- A. Cervical collar
- B. Cast
- C. Traction with weights and pulleys
- D. Turning frame
Correct Answer: C
Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
The nurse is caring for a client with paralysis as a result of a spinal cord injury. When planning care related to the musculoskeletal system, which immediate complication(s) should the nurse consider? Select all that apply.
- A. Calcium depletion
- B. Contractures
- C. Respiratory arrest
- D. Spinal shock
- E. Autonomic dysreflexia
Correct Answer: C,D
Rationale: Spinal shock is an immediate complication of spinal cord injury, and is characterized by immediate loss of all cord functions below the point of injury. When planning care for clients with a spinal cord injury, the nurse should consider immediate complications including respiratory arrest and spinal shock. Calcium depletion, contractures, and autonomic dysreflexia are all long-term complications of spinal cord injury leading to paralysis.