Nokea
The nurse is caring for a patient who had a spinal cord injury at C5 3 years ago. The nurse expects the plan of care will focus on the knowledge that the patient will be able to do which activity independently?
- A. feed self with setup and adaptive equipment.
- B. transfer self to wheelchair.
- C. stand erect with full leg braces.
- D. sit with good balance.
Correct Answer: A
Rationale: A cord injury at C5 allows for ability to drive an electric wheelchair with mobile hand supports and feed self with adaptive equipment.
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In which way will a nurse record the behavior when a patient with Alzheimer's disease attempts to eat using a napkin rather than a fork?
- A. Apraxia
- B. Agnosia
- C. Aphasia
- D. Dysphagia
Correct Answer: B
Rationale: Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage.
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
- A. Do you have any sensations of pins and needles in your feet?'
- B. Does the pain radiate from your back into your legs?'
- C. Can you describe the sensations you are having?'
- D. Do you ever have any nausea or dizziness?'
Correct Answer: C
Rationale: For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms.
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. Which is the appropriate nursing response to this finding?
- A. Cleanse nose with a soft cotton-tipped swab.
- B. Gently suction the nasal cavity.
- C. Gently wipe nose with absorbent gauze.
- D. Ask patient to blow his nose.
Correct Answer: C
Rationale: The patient's ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not mucus.
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and 'goose flesh.' Which action will be the initial nursing intervention based on these signs?
- A. Place patient in flat position and check temperature.
- B. Administer oxygen and check oxygen saturation.
- C. Place on side and check for leg swelling.
- D. Sit upright and check blood pressure.
Correct Answer: D
Rationale: These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. Which disorder is one example?
- A. Hypotension
- B. Alzheimer's disease
- C. Diabetes
- D. Parkinson disease
Correct Answer: A
Rationale: Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia.