Nokea
Which of the following nursing interventions is taken as a precautionary measure if shock develops when a client with spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein.
- B. Head and back are immobilized mechanically with a cervical collar and back support.
- C. Traction with weights and pulleys is applied.
- D. A turning frame is used.
Correct Answer: A
Rationale: IV access is critical for administering fluids and medications in shock.
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A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
- A. To reduce intraocular pressure
- B. To prevent acute tubular necrosis
- C. To promote osmotic diuresis to decrease ICP
- D. To draw water into the vascular system to increase blood pressure
Correct Answer: C
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue into the vascular system, reducing intracranial pressure (ICP). This is critical in cases of subdural hematoma, where increased ICP can lead to brain herniation and further neurological damage. The drug works by creating an osmotic gradient, pulling water from the extracellular space of the brain into the bloodstream, which is then excreted by the kidneys. This mechanism helps alleviate symptoms like restlessness, confusion, and pupil dilation caused by increased ICP.
MRS. Post is concerned about the effect of her diagnosis of systemic lupus erythematosus on childbearing. In discharge planning with Mrs. Post, you should
- A. instruct her to use an intrauterine device for birth control
- B. tell her pregnancy may cause an exacerbation of symptoms
- C. tell her that her symptoms will not change because of pregnancy
- D. instruct her to use birth control pills
Correct Answer: B
Rationale: Pregnancy can trigger lupus flares, requiring careful monitoring.
In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion?
- A. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs
- B. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible
- C. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm
- D. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm
Correct Answer: B
Rationale: Lower motor neuron lesions result in uncontrolled reflex erections.
In the development of the nervous system, which is the correct order of events?
- A. First, cells must be specified to be neurons, second, these neurons must make connections with their targets, third, the neurons must migrate to their final position, and fourth, the neurons refine their synaptic connections.
- B. First, cells must be specified to be neurons, second, the neurons must migrate to their final position, third, these neurons must make connections with their targets, and fourth, the neurons refine their synaptic connections.
- C. First, cells must migrate to their final position, second, these cells must be specified to be neurons, third, the neurons must make connections with their targets, and fourth, the neurons refine their synaptic connections.
- D. First, the prospective neurons must make connections with their targets, second, the neurons refine their synaptic connections, third, the neurons must migrate to their final position, and fourth, the cells are specified to become neurons.
Correct Answer: B
Rationale: The correct sequence of nervous system development involves: (1) specification of cells as neurons, (2) migration of neurons to their final positions, (3) formation of connections with targets, and (4) refinement of synaptic connections. This order ensures proper neural circuit formation and function. Specification occurs first, followed by migration, which positions neurons correctly. Axon outgrowth and target connection occur next, and finally, synaptic pruning and refinement optimize neural communication.
When an edrophonium (Tensilon) test is carried out, which of the following drugs must be available as an antidote?
- A. Atropine sulfate
- B. Diazepam (Valium)
- C. Ephedrine
- D. Corticosteroids
Correct Answer: A
Rationale: Atropine sulfate is used as an antidote for cholinergic crisis.