Nokea
The nurse is assessing a client with suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
- A. Respiratory acidosis
- B. Thready peripheral pulses
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis is a sign of neurogenic shock due to loss of sympathetic tone.
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The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
- A. The client and their family members will arrange for rehabilitation.
- B. The rehabilitation plan should be implemented early in the client's treatment.
- C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities.
- D. Long-term care should be arranged, as the client can no longer perform self-care.
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.
The following scenario applies to the next 1 items
The intensive care unit nurse has completed the assessment of a client
Item 1 of 1
Nurses' Notes
Progress Notes Orders
Day 2
1445: Physician at the bedside. The client is sedated, receiving mechanical ventilation via the #8 endotracheal tube. Current ventilator settings: assist control; rate 12/minute; tidal volume 450 mL; FiO 2 100%; positive end-expiratory pressure (PEEP) 5 cm H20. Intraventricular catheter present and zeroed and calibrated. No purposeful movement, and pupils were 3 mm equally round and sluggish to light. No abnormal posturing. + gag reflex; + corneal reflex. Lung sounds clear bilaterally, and the chest rises and falls synchronously with the ventilator. Peripheral pulses 2+ and S1 and S2 heart tones. Normoactive bowel sounds in all quadrants, no abdominal distention. Skin warm and dry. Indwelling urinary catheter patent and draining clear, concentrated urine. The client is currently positioned in a semi-Fowler position.
The nurse reviews the physician's orders
Click to specify if the order is indicated or requires follow-up with the physician:
- A. 0.45% saline infusion
- B. increase PEEP to 15 cm H20
- C. enoxaparin subcutaneously
- D. levetiracetam intravenous piggy-back
- E. pneumatic compression devices to the lower extremities
- F. repeated computed tomography (CT) scan
Correct Answer: B,B,B,A,A,A
Rationale: Hypotonic saline (0.45%) may worsen cerebral edema in brain injury; isotonic saline is preferred.
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
- A. Increased ability to focus
- B. Decreased muscle spasms
- C. Improved short-term memory
- D. Sleeping without awakening at night
Correct Answer: B
Rationale: Tizanidine is a muscle relaxant used to treat spasticity. A therapeutic effect is indicated by decreased muscle spasms. Increased focus, improved memory, and better sleep are not primary effects of tizanidine.
The nurse is performing a follow-up assessment on a client who was prescribed carbidopa/levodopa. Which assessment finding would indicate a therapeutic finding from this medication?
- A. Decrease in tremors
- B. Improvement in the excessive drooling
- C. Reduction in seizure activity
- D. Improvement in muscle spasticity
Correct Answer: A
Rationale: Carbidopa/levodopa is used for Parkinson's disease, and a decrease in tremors indicates therapeutic efficacy.
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 1 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.
Which of the following assessment findings require immediate follow-up?
- A. Neurological assessment findings
- B. Pulse and temperature
- C. Gastrointestinal assessment findings
- D. Influenza vaccination status
- E. Daily smoking habit
- F. Blood pressure and pulse oximetry reading
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.