Nokea
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find
- A. flaccidity of the upper extremities.
- B. hyperreflexia and spasticity of the upper extremities.
- C. independent use of upper extremities and efficient cough.
- D. impaired diaphragmatic function requiring ventilator support.
Correct Answer: C
Rationale: Patients paralyzed below T4 typically retain independent use of upper extremities.
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Your neighbor tells you about her preteen son. It seems that he has an ongoing head cold. His sinus is congested; he is not eating regularly and is losing weight. Your neighbor reports that his head cold is so bad that he has to wear sunglasses even in the house. She asks him to remove the glasses but he becomes agitated. You noticed her son is around the neighborhood during school hours when the rest of the family is working. What is your best response?
- A. You better take your son to your doctor immediately. He might have more than a head cold.
- B. Do you notice any money missing from your house?
- C. Is your son going to school?
- D. Your son's condition and behavior does not seem normal. Why don't you ask your practitioner to assess your son.
Correct Answer: D
Rationale: Encouraging professional assessment addresses potential substance abuse or other health issues.
Donna is a healthy, 46-year-old woman scheduled for elective surgery next week. You would include in her preoperative preparation
- A. A pulmonary function test and chest x-ray.
- B. A complete blood count (CBC), chemistry panel, and pregnancy test.
- C. Urine culture, thyroid panel, and cortisol level.
- D. Glucose tolerance test, ankle-brachial index, and electrocardiogram (EKG).
Correct Answer: B
Rationale: Basic lab tests ensure the patient is fit for surgery.
What is the primary complication of untreated otitis media?
- A. Hearing loss
- B. Meningitis
- C. Cholesteatoma
- D. All of the above
Correct Answer: D
Rationale: Untreated otitis media can lead to serious complications, including hearing loss, meningitis, and cholesteatoma.
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
Which of the following comments should be given first consideration?
- A. There was a lot of blood and we used three bandages
- B. He pulled the stick out, just now, because it was hurting him
- C. The stick was really dirty and covered with mud
- D. He's a diabetic, so he needs attention right away
Correct Answer: B
Rationale: Pulling out the stick could have caused internal injury, making this the most urgent concern.