Nokea
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.
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Which is a common cognitive problem associated with Parkinson’s disease?
- A. Emotional lability.
- B. Depression.
- C. Memory deficits.
- D. Paranoia.
Correct Answer: B
Rationale: Depression (B) is a common cognitive/emotional problem in Parkinson’s due to dopamine dysregulation and chronic illness impact. Emotional lability (A) is less common, memory deficits (C) occur later, and paranoia (D) is not typical.
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client?
- A. Joint pain of the neck and jaw.
- B. Unconscious grinding of the teeth during sleep.
- C. Sudden severe unilateral facial pain.
- D. Progressive loss of calcium in the nasal septum.
Correct Answer: C
Rationale: Trigeminal neuralgia causes sudden, severe, unilateral facial pain (C) due to irritation of the trigeminal nerve. Joint pain (A) is unrelated, teeth grinding (B) is bruxism, and calcium loss (D) is not a feature.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
- A. The assistant places a gait belt around the client's waist prior to ambulating.
- B. The assistant places the client on the back with the client's head to the side.
- C. The assistant places a hand under the client's right axilla to move up in bed.
- D. The assistant praises the client for attempting to perform ADLs independently.
Correct Answer: C
Rationale: Placing a hand under the axilla (C) to move a client with right-sided paralysis risks shoulder subluxation or injury to the weak side. A gait belt (A) is appropriate for safe ambulation, positioning with head to the side (B) prevents aspiration, and praising independence (D) is therapeutic.
Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
- A. Poor skin turgor
- B. Decerebrate posturing
- C. Deep tendon reflexes
- D. Absent corneal reflex
- E. Dilated nonreactive pupils
- F. Dry mucous membranes
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.