After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A. Quadriplegia with gross arm movement and diaphragmatic breathing. B. Quadriplegia and loss of respiratory function. C. Paraplegia with intercostal muscle loss. D. Loss of bowel and bladder control. … Read More »
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension… Read More »
A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto a stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C.… Read More »
A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client’s airway for rescue breathing? A. By inserting a nasopharyngeal airway. B. By inserting an oropharyngeal airway. C. By performing a jaw thrust maneuver. D. By performing the… Read More »
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A.… Read More »
Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig’s sign B. Negative Brudzinski’s sign C. Positive homan’s sign D. Negative Kernig’s sign Correct Answer: A. Positive Kernig’s sign A positive Kernig’s sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space.… Read More »
During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to: A. Use the pointed end of the reflex hammer when striking the Achilles’ tendon. B. Support the joint where the tendon is being tested. C. Tap the tendon slowly and softly. D.… Read More »
Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A. Congenital anatomic abnormality of the meninges. B. Lack of acquired resistance to the various etiologic organisms. C. Occlusion or narrowing of the CSF pathway. D. Natural affinity of the CNS to certain… Read More »
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client’s plan of care? A. Disturbed sensory perception (visual) B. Self-care deficit: Dressing/grooming C. Impaired verbal communication D. Risk for injury Correct… Read More »
The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A. desmopressin (DDAVP, Stimate) B. Dexamethasone (Decadron) B. Dexamethasone (Decadron) C. ethacrynic acid (Edecrin)… Read More »