Nokea
A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge?
- A. Rehabilitation measures cannot be initiated until spinal shock has resolved.
- B. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia.
- C. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder.
- D. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic functions are not affected.
Correct Answer: C
Rationale: Spinal shock resolves with the return of reflex activity.
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Proper body alignment of the hemiplegic patient with the use of a footboard, trochanter rolls, and pillows will minimize the development of
- A. plantar extension
- B. shoulder abduction
- C. internal hip rotation
- D. external hip rotation
Correct Answer: A
Rationale: Footboards prevent plantar extension deformities.
A laminectomy and spinal fusion are performed on a patient with a herniated lumbar intervertebral disc. During the postoperative period, which finding is of most concern to the nurse?
- A. Paralytic ileus
- B. Urinary incontinence
- C. Greater pain at the graft site than at the lumbar incision site
- D. Leg and arm movement and sensation unchanged from preoperative status
Correct Answer: B
Rationale: Urinary incontinence may indicate nerve damage.
Which of these diseases can be prevented with a vaccine for humans?
- A. eastern equine encephalitis
- B. western equine encephalitis
- C. West Nile encephalitis
- D. Japanese encephalitis
Correct Answer: D
Rationale: Step 1: Identify the disease - Japanese encephalitis is caused by a virus transmitted by mosquitoes.
Step 2: Understand the role of a vaccine - a vaccine stimulates the immune system to produce antibodies to fight the virus.
Step 3: Vaccines prevent future infections - by administering a vaccine for Japanese encephalitis, individuals can develop immunity and prevent the disease.
Step 4: Therefore, the correct answer is D because a vaccine is available to prevent Japanese encephalitis.
Summary: A, B, and C are incorrect because there are no vaccines available for eastern equine encephalitis, western equine encephalitis, and West Nile encephalitis, respectively.
Which of the following findings would indicate a change in a patient's mental status?
- A. Sudden onset of confusion or disorientation.
- B. Steady gait and normal speech.
- C. Clear and coherent communication.
- D. Stable vital signs and regular breathing.
Correct Answer: A
Rationale: A sudden onset of confusion or disorientation is a key indicator of a change in mental status. Steady gait, clear communication, and stable vital signs are normal findings.
You are providing care for a patient with an acute hemorrhagic stroke. The patient's husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
- A. Your wife was not admitted within the time frame that alteplase is usually given.
- B. This drug is used primarily for patients who experience an acute heart attack.
- C. Alteplase dissolves clots and may cause more bleeding into your wife's brain.
- D. Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase.
Correct Answer: C
Rationale: Alteplase increases the risk of bleeding, making it contraindicated in hemorrhagic stroke.