Nokea
Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action?
- A. Institute frequent turning and repositioning
- B. Use tracheal suctioning to remove secretions
- C. Assess lung sounds and respiratory rate and depth
- D. Prepare the patient for endotracheal intubation and mechanical ventilation
Correct Answer: C
Rationale: Assessment ensures proper diagnosis before intervention.
You may also like to solve these questions
In providing care for patients with chronic, progressive neurologic disease, what is the major goal of treatment that the nurse works toward?
- A. Meet the patient's personal care needs.
- B. Return the patient to normal neurologic function.
- C. Maximize neurologic functioning for as long as possible.
- D. Prevent the development of additional chronic diseases.
Correct Answer: C
Rationale: Maximizing function for as long as possible is the primary goal
What is a normal response when assessing the pupillary light reflex?
- A. Pupils constrict in response to light and then dilate when light is removed.
- B. Pupils remain dilated regardless of light exposure.
- C. Pupils remain constricted regardless of light exposure.
- D. Pupils respond unevenly to light.
Correct Answer: A
Rationale: The normal pupillary light reflex involves constriction in response to light and dilation when light is removed. Uneven or absent responses are abnormal.
What part of a neuron is responsible for receiving information?
- A. axon
- B. terminal bre
- C. dendrite
- D. myelin sheath
Correct Answer: C
Rationale: Dendrites are the part of a neuron responsible for receiving information from other neurons. They are branched structures that extend from the cell body and contain receptors for neurotransmitters. When neurotransmitters bind to these receptors, they generate electrical signals that travel toward the cell body, initiating communication between neurons. Dendrites play a crucial role in integrating incoming signals and determining whether the neuron will fire an action potential.
With regard to nystagmus:
- A. caloric nystagmus occurs when iced water is poured into the ear
- B. vestibular nystagmus occurs as a consequence of head rotation
- C. optokinetic nystagmus occurs as a consequence of the relative motion of the visual field
- D. all above
Correct Answer: D
Rationale: Caloric, vestibular, and optokinetic nystagmus are all types of nystagmus caused by specific stimuli, such as temperature changes, head rotation, or visual field motion.
A nursing intervention that would be appropriate to provide respite care?
- A. Help the wife to arrange for adult day care for the patient.
- B. Encourage permanent placement of the patient in the Alzheimer's unit of a long-term care facility.
- C. Refer the wife to a home health agency to arrange daily home nursing visits to assist with the patient's care.
- D. Arrange for hospitalization of the patient for 3 or 4 days so that the wife can visit out-of-town friends and relatives.
Correct Answer: A
Rationale: Adult day care provides temporary relief for caregivers