Nokea
Which of the following actions should the nurse first take if a client with spinal cord injury at T3 complains of a sudden severe headache, nasal congestion, flushed skin, and goose-bumps?
- A. Raise the client's head
- B. Place the client on a firm mattress
- C. Call the physician
- D. Administer an analgesic to relieve the pain
Correct Answer: C
Rationale: These symptoms suggest autonomic dysreflexia, requiring immediate medical attention.
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A 40 year old man suffered a whiplash injury to his neck and now complains of pain along the lateral aspect of his left forearm, and there is weakness of his left biceps. What is the most likely cause of his symptoms?
- A. Prolapsed 4th cervical disc impinging on C4 root
- B. Prolapsed 4th cervical disc impinging on C5 root
- C. Prolapsed 5th cervical disc impinging on C6 root
- D. Prolapsed 6th cervical disc impinging on C6 root
Correct Answer: C
Rationale: A prolapsed C5-C6 disc impinging on the C6 root can cause pain in the lateral forearm and weakness in the biceps, which is innervated by the C6 nerve root.
To prevent strain on Mr. Tucker's back muscles, which nursing action is INAPPROPRIATE?
- A. To place him on bed pan, logroll using a turning sheet
- B. When lying on his side, flex upper leg and place a pillow between his knees
- C. When lying on his back, place pillows under entire length of his knees
- D. To turn him on his side, gently turn his shoulders and upper trunk first, prop with a pillow, then turn his pelvis and lower limbs
Correct Answer: D
Rationale: Turning the pelvis and lower limbs last can strain back muscles.
When the nurse shines a light in a patient's left pupil, both of the pupils constrict. What type of response should the nurse document?
- A. Direct
- B. Abnormal
- C. Consensual
- D. Accommodation
Correct Answer: C
Rationale: A consensual response occurs when light shone in one eye causes both pupils to constrict. A direct response involves constriction of the illuminated pupil only, while accommodation is the ability to focus on near objects. Documenting a consensual response is important for assessing cranial nerve function.
During neurologic assessment of the older adult, what should the nurse expect to find?
- A. Absent deep tendon reflexes
- B. Below-average intelligence score
- C. Decreased sensation of touch and temperature
- D. Decreased frequency of spontaneous awakening
Correct Answer: C
Rationale: Older adults often exhibit decreased sensation of touch and temperature.
The patient with apraxia cannot:
- A. name his fingers
- B. carry out an imagined act
- C. draw simple diagrams
- D. speak fluently
Correct Answer: B
Rationale: Carry out an imagined act is the correct answer because apraxia is a motor disorder characterized by the inability to perform purposeful movements, despite having the physical ability and desire to do so. This condition results from damage to the parietal lobe or other areas involved in motor planning.