Nokea
When the nurse performs a physical assessment, which finding is most indicative of the client's disorder?
- A. Quivering eye movement
- B. Muscle spasms in the lower extremities
- C. Loss of motor function on the affected side
- D. Unilateral facial paralysis
Correct Answer: D
Rationale: Unilateral facial paralysis is the hallmark sign of Bell's palsy, caused by inflammation of cranial nerve VII.
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The nurse reviews the chart of the client who had a T12 SCI 12 years ago and is receiving baclofen through an intrathecal infusion pump. Which chart information in the exhibit is most important for the nurse to discuss with the HCP?
- A. Assessment findings
- B. Orthostatic hypotension
- C. Laboratory test results
- D. Prescribed medications
Correct Answer: A
Rationale: Exaggerated spasticity, muscle rigidity, and tinnitus are adverse effects of baclofen (Lioresal) that the nurse should discuss with the HCP. The client had a minimal drop in BP from lying to standing and does not have orthostatic hypotension. The WBC and liver enzymes are WNL. The glucose is not significantly elevated and would not warrant notifying the HCP. All prescribed medications are appropriate for the client who has a T12 SCI.
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
- A. Discuss how to correctly remove the insertion pins.
- B. Instruct the client to report reddened or irritated skin areas.
- C. Inform the client that the vest liner cannot be changed.
- D. Encourage the client to remain in the recliner as much as possible.
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (B) prevents pressure ulcers. Removing pins (A) is done by providers, the vest liner can be changed (C), and prolonged recliner use (D) risks immobility complications.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.
Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?
- A. Abnormal diaphoresis.
- B. A severe throbbing headache.
- C. Sudden loss of motor function.
- D. Spastic skeletal muscle movement.
Correct Answer: B
Rationale: Autonomic dysreflexia in SCI causes severe headache (B) due to hypertensive crisis from a trigger like bladder distention. Diaphoresis (A) is secondary, motor loss (C) is expected, and spasticity (D) is chronic.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.