Nokea
After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the:
- A. Abdomen
- B. Arms
- C. Legs
- D. Chest
Correct Answer: C
Rationale: L3 spinal cord injury affects lower extremity motor function, leading to leg paralysis.
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The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 5 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each physician order, click to specify the appropriate nursing intervention: Lumbar puncture
- A. Assess the client for an allergy to contrast dye
- B. Obtain laboratory work prior to the procedure
- C. Position the client flat before the procedure
- D. Monitor the client's temperature for efficacy
- E. Place an incontinence pad under the client for increased urinary output
- F. administer immediately after lumbar puncture
- G. establish a patent vascular access device
Correct Answer: B,F,G
Rationale: Obtaining labs (e.g., coagulation studies) ensures safety before lumbar puncture. Ketorolac may help reduce fever; monitoring temperature assesses its efficacy. Ceftriaxone is administered post-lumbar puncture to treat confirmed or suspected bacterial meningitis. Padding the bed prevents injury during potential seizures.
The nurse assesses a client with damage to cranial nerve III. Which finding would be expected?
- A. Ptosis
- B. Anosmia
- C. Uvula deviation
- D. Asymmetric facial movement
Correct Answer: A
Rationale: Cranial nerve III (oculomotor) damage causes ptosis due to impaired eyelid elevation.
The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
- A. Cocaine intoxication
- B. Respiratory acidosis
- C. Tonic-clonic seizures
- D. Aggression
Correct Answer: B
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.
Which statement below relating to pain and pain perception is accurate?
- A. Allodynia is the pathophysiological absence of pain when a painful stimulus is applied.
- B. Scientific evidence does not support the presence of pain during neonatal circumcision.
- C. Hyperalgesia is the opposite of hyperpathia, both of which are abnormal pain responses.
- D. The perception of pain and its impact on clients vary greatly among individuals.
Correct Answer: D
Rationale: Pain perception varies widely due to individual physiological and psychological factors.
The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?
- A. Prepares to administer intravenous valproate.
- B. Place the client in a lateral position.
- C. Activates the rapid response team (RRT).
- D. Loosens any restrictive clothing.
Correct Answer: A
Rationale: Valproate is not a first-line treatment for status epilepticus; benzodiazepines like lorazepam are preferred.