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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.
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Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured left leg?
- A. Assessing the neurological status.
- B. Immobilizing the fractured leg.
- C. Monitoring the client's output.
- D. Starting an 18-gauge saline lock.
Correct Answer: A
Rationale: Trauma patients require a primary survey, prioritizing neurological status (A) to detect head injuries, which are life-threatening. Immobilizing the leg (B), monitoring output (C), and IV access (D) follow.
The client diagnosed with ALS asks the nurse, 'I know this disease is going to kill me. What will happen to me in the end?' Which statement by the nurse would be most appropriate?
- A. You are afraid of how you will die?'
- B. Most people with ALS die of respiratory failure.'
- C. Don’t talk like that. You have to stay positive.'
- D. ALS is not a killer. You can live a long life.'
Correct Answer: B
Rationale: Providing factual information about respiratory failure (B) addresses the client’s question honestly while respecting their need for clarity. Reflecting fear (A) is vague, dismissing concerns (C) is untherapeutic, and denying prognosis (D) is inaccurate.
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.
The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement?
- A. Discuss the need to be placed in a long-term care facility.
- B. Explain how to care for a sigmoid colostomy.
- C. Assist the client to prepare an advance directive.
- D. Teach the client how to use a motorized wheelchair.
Correct Answer: C
Rationale: ALS progression leads to significant disability, making advance directives (C) critical to ensure the client’s wishes are respected. Long-term care (A) is premature, colostomy (B) is unrelated, and wheelchair use (D) is secondary.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
- A. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
- B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson’s disease.
- C. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training activities.
- D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
Correct Answer: A
Rationale: Feeding a client with swallowing difficulty (A) requires nursing judgment to assess aspiration risk, so it should not be delegated. Turning/positioning (B), assisting with toileting (C), and vital signs (D) are within UAP scope.