Nokea
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
- A. Extreme thirst
- B. Intake and output
- C. Nutritional status
- D. Body temperature
Correct Answer: D
Rationale: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.
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The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful?
- A. Adoption is an option to complete your family but not put your life in jeopardy.
- B. Conception is not impaired, the birth process is determined with the health care provider.
- C. Birth via surrogate is best because your baby can be implanted in another woman.
- D. Sterilization is best; it would be difficult to care for a baby in your condition.
Correct Answer: B
Rationale: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
- A. Radiography
- B. Myelography
- C. Neurologic examination
- D. Computed tomography (CT) scan
Correct Answer: C
Rationale: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.
The nurse is caring for a client with paralysis as a result of a spinal cord injury. When planning care related to the musculoskeletal system, which immediate complication(s) should the nurse consider? Select all that apply.
- A. Calcium depletion
- B. Contractures
- C. Respiratory arrest
- D. Spinal shock
- E. Autonomic dysreflexia
Correct Answer: C,D
Rationale: Spinal shock is an immediate complication of spinal cord injury, and is characterized by immediate loss of all cord functions below the point of injury. When planning care for clients with a spinal cord injury, the nurse should consider immediate complications including respiratory arrest and spinal shock. Calcium depletion, contractures, and autonomic dysreflexia are all long-term complications of spinal cord injury leading to paralysis.
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
- A. Sciatic nerve pain
- B. Herniation
- C. Paresthesia
- D. Paralysis
Correct Answer: C
Rationale: A client reports numbness and tingling in an area is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
A middle-aged client has scheduled a sick visit to the physician's office, reporting symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and shows potential causes of the pain. Which area of the drawing would the nurse emphasize?
- A. Spinal cord pathway
- B. Nucleus pulposus
- C. Bony vertebrae
- D. Associated musculature
Correct Answer: B
Rationale: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms.