Nokea
The nurse who assesses for cultural influences, values cultural diversity, and incorporates cultural knowledge in practice is said to be culturally
Correct Answer: competent
Rationale: A culturally competent nurse includes knowledge of cultural values and influences in their nursing practice.
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The spinal cord injury patient has paralysis of all extremities and bowel and bladder disturbance. The nurse recognizes the injury as most likely occurring at what vertebral level?
- A. C1 to C2
- B. C3 to C4
- C. C2 to C7
- D. C4 to C7
Correct Answer: C
Rationale: The vertebral level of injury for a cervical cord is C2 to C7 if the patient has paralysis of all extremities and trunk, and has lost control of bowel and bladder function.
The patient with a brain injury is beginning to regain memory. The nurse explains to the family that what will most likely occur?
- A. The patient will become less combative.
- B. The patient will become angrier.
- C. The patient will become more depressed.
- D. The patient will wish to retire.
Correct Answer: C
Rationale: Generally, the more the memory improves, the more the patient becomes depressed.
When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on which goals?
- A. Returning to normal
- B. Independence
- C. Employment
- D. Promotion of health
Correct Answer: B
Rationale: The focus on rehabilitation is on enabling the individual to move from a totally dependent state to a level of independence.
What should the nurse do to decrease the potential for a deep vein thrombosis (DVT) in a patient who is a paraplegic from a spinal cord injury?
- A. Massage the patient's legs daily.
- B. Perform passive range-of-motion exercises.
- C. Encourage frequent warm baths.
- D. Allow the patient's legs to dangle for a period of 10 minutes several times a day.
Correct Answer: B
Rationale: DVTs are a problem for patients with a spinal cord injury. Passive range-of-motion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT.
The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering which condition?
- A. Paresis
- B. Heterotopic ossification
- C. Postural hypotension
- D. Autonomic dysreflexia
Correct Answer: D
Rationale: Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system. It is the result of stimulation of the body below the level of the spinal cord injury.