Nokea
The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse’s conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply.
- A. Blurred vision
- B. BP 198/102 mm Hg
- C. Heart rate 150 bpm
- D. Extreme headache
- E. Sweaty face and arms
Correct Answer: A,B,D,E
Rationale: Blurred vision results from the hypertension occurring with autonomic dysreflexia. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. Headache results from the hypertension occurring with autonomic dysreflexia. Sweating results from the sympathetic stimulation above the level of injury.
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The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
- A. Note the first thing the client does in the seizure.
- B. Assess the size of the client’s pupils.
- C. Determine if the client is incontinent of urine or stool.
- D. Provide the client with privacy during the seizure.
Correct Answer: A
Rationale: Noting the first action (A) helps identify the seizure type and focus, aiding diagnosis and treatment. Pupil size (B), incontinence (C), and privacy (D) are secondary to ensuring safety and documenting the event.
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
Which client behavior during a seizure requires immediate intervention?
- A. Lip smacking
- B. Rhythmic limb jerking
- C. Incontinence
- D. Tongue biting
Correct Answer: D
Rationale: Tongue biting during a seizure can cause airway obstruction or severe injury, requiring immediate intervention to protect the airway.
Which preoperative assessment is most important to document as a basis for postoperative comparison?
- A. Motor strength in all extremities
- B. Sodium and potassium laboratory values
- C. Pulses in lower extremities
- D. Glucometer blood glucose levels
Correct Answer: A
Rationale: Motor strength assessment provides a baseline to detect postoperative neurological deficits from brain tumor surgery.