Nokea
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and 'goose flesh.' Which action will be the initial nursing intervention based on these signs?
- A. Place patient in flat position and check temperature.
- B. Administer oxygen and check oxygen saturation.
- C. Place on side and check for leg swelling.
- D. Sit upright and check blood pressure.
Correct Answer: D
Rationale: These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.
You may also like to solve these questions
The waxy substance that covers the neuron fibers and increases the rate of transmission of impulses is the ___
Correct Answer: myelin
Rationale: Myelin is the waxy substance that covers the neuron fibers (axons and dendrites) and increases the rate of transmission of impulses.
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. Which disorder is one example?
- A. Hypotension
- B. Alzheimer's disease
- C. Diabetes
- D. Parkinson disease
Correct Answer: A
Rationale: Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia.
In which way will the nurse instruct a patient with Parkinson disease to improve activity level?
- A. To use a soft mattress to relax the spine.
- B. To walk with a shuffling gait to avoid tripping.
- C. To walk with hands folded behind back to help balance.
- D. To sit in hard chair with arms for posture control.
Correct Answer: C
Rationale: The patient with Parkinson disease can improve the activity level holding the hands folded behind to keep better balance and keep the arms from hanging stiffly at the side. The patient should be sleeping on a firm mattress without a pillow to prevent spinal curvature, Walk with a lifting of the feet to avoid tripping and 'freezing.'
Which issue is the basic problem that prompts most of the early signs of Alzheimer's disease (AD)?
- A. Changes in mood
- B. Misplacing things
- C. Memory loss that disrupts daily life
- D. Problems with words in speaking
Correct Answer: C
Rationale: Memory loss that disrupts daily life is the basic problem that prompts most of the early signs of AD.
In which way will a nurse record the behavior when a patient with Alzheimer's disease attempts to eat using a napkin rather than a fork?
- A. Apraxia
- B. Agnosia
- C. Aphasia
- D. Dysphagia
Correct Answer: B
Rationale: Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage.