Nokea
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.
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When is the best time to clip the client's hair?
- A. The night before surgery
- B. In the morning, after a shower
- C. Right before entering the operating room
- D. Before surgery, in the operating room area
Correct Answer: D
Rationale: Clipping hair in the operating room area minimizes infection risk by reducing the time the scalp is exposed.
The nurse arrives at the scene of a motor-vehicle accident and the car is leaking gasoline. The client is in the driver's seat of the car complaining of not being able to move the legs. Which actions should the nurse implement? List in order of priority.
- A. Move the client safely out of the car.
- B. Assess the client for other injuries.
- C. Stabilize the client's neck.
- D. Notify the emergency medical system.
- E. Place the client in a functional anatomical position.
Correct Answer: C,B,A,D,E
Rationale: Stabilize the client’s neck (C): Prevents spinal injury. 2. Assess for other injuries (B): Identifies life-threatening issues. 3. Move the client safely (A): Removes from gasoline danger. 4. Notify EMS (D): Ensures professional help. 5. Place in anatomical position (E): Least urgent.
The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
- A. Decerebrate posturing observed
- B. Decorticate posturing observed
- C. Positive Kernig’s sign observed
- D. Seizure activity observed
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies.
- A. The client has a recurrent temperature of 100.6°F.
- B. The client has a decreased complaint of headache.
- C. The client comments that the meal has no taste.
Correct Answer: B
Rationale: A fever of 100.6°F (B) in encephalitis may indicate worsening infection or inflammation, requiring immediate intervention. Decreased headache (C) suggests improvement, and taste loss (D) is less urgent. Facial palsies are noted but not an option.