Nokea
When preparing the client for an EEG, which nursing action is most appropriate?
- A. Administer a sedative 1 hour before the test.
- B. Withhold food and water after midnight on the day of the test.
- C. Assist with shampooing the client's hair.
- D. Take the client's blood pressure while lying and sitting.
Correct Answer: C
Rationale: Shampooing the client's hair ensures a clean scalp, improving electrode contact for an accurate EEG.
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In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.
Which postoperative complication should the nurse monitor most closely after a craniotomy?
- A. Hypotension
- B. Cerebrospinal fluid leak
- C. Mild fever
- D. Constipation
Correct Answer: B
Rationale: A cerebrospinal fluid leak is a critical complication post-craniotomy, increasing infection risk and requiring immediate intervention.
The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem?
- A. Complete spinal cord transection
- B. Spinal shock
- C. An upper motor neuron injury
- D. Quadriplegia
Correct Answer: B
Rationale: A complete spinal cord transection results in no reflexes or movement distal to the injury. With a C4 injury, the client initially would have some difficulty breathing due to edema of the spinal cord that occurs above the level of the injury. The client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis, and absence of muscle contractions occur. Spinal shock lasts 7 to 20 days, and the SCI cannot be classified accurately until spinal shock resolves. An injury of the upper motor neuron results in spastic paralysis. Quadriplegia, now termed tetraplegia, is paralysis involving all four extremities.
The nurse is assessing a client with a history of transient ischemic attacks (TIAs). Which finding is most concerning and should be reported immediately?
- A. Mild headache for 2 days
- B. Transient numbness in the left arm
- C. Slight dizziness when standing
- D. Occasional forgetfulness
Correct Answer: B
Rationale: Transient numbness in the left arm may indicate a TIA, which requires immediate reporting due to the risk of progression to a stroke.
Which assessment finding indicates a potential spinal shock in a client with a spinal cord injury?
- A. Flaccid paralysis below the injury
- B. Spastic movements in lower limbs
- C. Intact sensation below the injury
- D. Elevated blood pressure
Correct Answer: A
Rationale: Spinal shock is characterized by flaccid paralysis and loss of reflexes below the injury level immediately after a spinal cord injury.