Nokea
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
- A. Determine the level at which the patient has intact sensation.
- B. Assess the level at which the patient has retained mobility.
- C. Check blood pressure and pulse for signs of spinal shock.
- D. Monitor respiratory effort and oxygen saturation level.
Correct Answer: D
Rationale: Respiratory function is critical at this level of injury and must be assessed immediately.
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To determine the extent of Mr. Smith's head injury, what baseline nursing assessment is most important?
- A. Respiratory status
- B. Motor strength
- C. Urinary output
- D. Gastrointestinal function
Correct Answer: A
Rationale: Respiratory status is crucial in assessing head injuries due to potential brainstem involvement.
Brown-Sequard syndrome develops with the following damage of the spinal cord:
- A. complete transversal
- B. anterior horns
- C. half transversal
- D. posterior horns
Correct Answer: C
Rationale: Half transversal is the correct answer because Brown-Sequard syndrome results from damage to one side of the spinal cord. This leads to ipsilateral motor paralysis and loss of proprioception, and contralateral loss of pain and temperature sensation due to the crossing of spinothalamic tract fibers.
Dilatation of the peripheral arterial blood vessels can be caused by:
- A. thromboxane A2
- B. adenosine diphosphate
- C. endothelin
- D. prostaglandins
Correct Answer: D
Rationale: Prostaglandins, particularly prostacyclin (PGI2), are potent vasodilators. Thromboxane A2, adenosine diphosphate, and endothelin are vasoconstrictors and do not cause peripheral arterial dilatation.
To assess for a possible seizure disorder, the nurse should:
- A. Observe the patient for any involuntary movements or altered consciousness.
- B. Measure the patient's heart rate.
- C. Inspect the patient's skin for rashes.
- D. Check the patient's blood glucose levels.
Correct Answer: A
Rationale: Seizure disorders are assessed by observing for involuntary movements or altered consciousness. Heart rate, skin rashes, and blood glucose levels are unrelated to seizure assessment.
Before initiating levodopa for a client with Parkinson's disease, Nurse Allen ensures she is well-informed about the medication and its implications. What crucial information should Nurse Allen be aware of regarding levodopa?
- A. Levodopa's absorption can be insufficient if it is administered alongside meals.
- B. Levodopa has the potential to induce side effects such as orthostatic hypotension.
- C. Levodopa can lead to an initial feeling of euphoria, which is then followed by a phase of depression.
- D. Levodopa administration requires consistent monitoring through weekly laboratory tests.
Correct Answer: A
Rationale: Levodopa absorption is significantly reduced when taken with protein-rich meals, so it should be administered on an empty stomach or with a low-protein snack.