Nokea
A patient arrives at an urgent care centre with a deep puncture wound after stepping on a nail. The patient reports having had a tetanus booster 7 years ago. Which of the following actions should the nurse anticipate?
- A. IV infusion of tetanus immune globulin (TIG)
- B. Administration of the tetanus-diphtheria (Td) booster
- C. Intradermal injection of an immune globulin test dose
- D. Initiation of the tetanus-diphtheria immunization series
Correct Answer: B
Rationale: If the patient has not been immunized within 5 years and presents with an open wound, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.
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The nurse is assessing a patient with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?
- A. Triggers that lead to facial pain
- B. Visual problems caused by ptosis
- C. Poor appetite caused by a loss of taste
- D. Weakness on the affected side of the face
Correct Answer: A
Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
The nurse is facilitating a bladder training program for a patient who had a spinal cord injury 2 weeks ago and is stable. Which of the following amounts of daily fluid should the nurse include in the patient plan of care to maintain the patient on fluid restriction?
- A. 600-800 mL
- B. 1000-1200 mL
- C. 1400-1600 mL
- D. 1800-2000 mL
Correct Answer: D
Rationale: Many patients are maintained on fluid restriction of 1800-2000 mL/day to facilitate a bladder training program, and urinary output is monitored closely.
Which of the following actions should the nurse take when assessing a patient with trigeminal neuralgia?
- A. Examine the mouth and teeth thoroughly.
- B. Have the patient clench and relax the jaw and eyes.
- C. Identify trigger zones by lightly touching the affected side.
- D. Gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
The nurse is caring for a patient with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
- A. Hypotension, bradycardia, and warm extremities
- B. Involuntary, spastic movements of the arms and legs
- C. Hyperactive reflex activity below the level of the injury
- D. Lack of movement or sensation below the level of the injury
Correct Answer: A
Rationale: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not neurogenic shock.
The nurse is caring for a patient who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?
- A. Assessment of the patient for left leg pain
- B. Assessment of the patient for left arm weakness
- C. Positioning the patient's right leg when turning the patient
- D. Teaching the patient to look at the left leg to verify its position
Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.