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The student nurse asks the nurse, 'Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?' The nurse would base the response on which scientific rationale?
- A. This is part of the routine neurological examination.
- B. This is done to determine if the client has diplopia.
- C. This assesses the amount of brain damage.
- D. This is done to indicate if there is a rebound effect on the brain.
Correct Answer: B
Rationale: Frontal head injuries may affect the occipital lobe or optic pathways, causing diplopia (double vision, B). Routine exams (A) are broader, brain damage (C) is not specific, and rebound effect (D) is not a term used here.
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The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson's disease?
- A. Ascending paralysis and pain.
- B. Masklike facies and pill rolling.
- C. Diplopia and ptosis.
- D. Dysphagia and dysarthria.
Correct Answer: B
Rationale: Masklike facies and pill-rolling tremors (B) are hallmark Parkinson’s signs due to dopamine deficiency. Paralysis/pain (A) suggest Guillain-Barré, diplopia/ptosis (C) indicate myasthenia gravis, and dysphagia/dysarthria (D) are later symptoms.
Which assessment finding in a client post-diskectomy indicates a potential complication?
- A. Mild incisional pain
- B. Numbness in the toes
- C. Clear urine output
- D. Stable vital signs
Correct Answer: B
Rationale: Numbness in the toes may indicate nerve compression or damage, a potential complication requiring further evaluation.
The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statements by the nurse will be helpful to the client? Select all that apply.
- A. “You need to continue to use contraceptives if you do not wish to have children.”
- B. “Unfortunately, your injury prevents you from being able to conceive children.”
- C. “Because feeling is affected, it is not likely that you will be able to deliver a baby.”
- D. “Sexual intercourse is generally prohibited because it can worsen your condition.”
- E. “You can engage in sexual intimacy, but you may not be able to feel an orgasm.”
Correct Answer: A,E
Rationale: Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. The client with an incomplete T6 SCI is able to get pregnant. Although the client may not feel the onset of labor, she may still be able to deliver the baby vaginally or via cesarean section. Sexual intercourse is allowable and would not worsen the client’s condition. The female may not be able to feel an orgasm. The client may not be able to feel an orgasm after an incomplete T6 SCI.