NUR 2755 Multidimensional Care IV
MDC4 Final Exam
A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110 mm Hg. What is the nurse's priority action at this time?
- Perform a bladder assessment
- Insert an indwelling urinary catheter
- Place the patient in a sitting position
- Turn on a fan to cool the patient
Correct Answer:
- Place the patient in a sitting position
- The first priority for someone experiencing autonomic dysreflexia is placing
patient in a sitting position or return to a previous safe position)
A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider?
- Purulent drainage from the pin sites on the client's forehead
- Painful pressure injury under the collar
- Inability to move legs or feet
- Oxygen saturation of 95% on room air
Correct Answer:
- purulent drainage from the pin sites on the client's forehead
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which statement by a client who had a transient ischemic attack and is at risk for stroke indicates a need for further health teaching by the nurse?
- "I'm glad I can keep eating protein like red meat."
- "I'll try to walk at least 20 to 30 minutes each day."
- "I'm going to talk to my doctor about a weight loss plan."
- "I plan to include more fruits and vegetables in my diet."
Correct Answer:
- "I'm glad I can keep eating protein like red meat."
(lifestyle changes--> smoking cessation, heart-healthy diet rich in fruits and vegetables and low in saturated fats (including red meats); and regular activity, including planned exercise.
The nurse is caring for a client treated with alteplase following a stroke. Which assessment findings is the highest priority for the nurse to report to the primary health care provider?
- client has a new-onset mild headache
- Client's blood pressure is 194/120 mm Hg
- Client has left hemiparesis
- Client continues to be drowsy
Correct Answer:
- Client's blood pressure is 194/120 mm Hg
The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client?
- refer the client to the speech-language pathologist
- speak loudly to help the client interpret what is being said.
- Provide pictures to help the client understand 2 / 4
- Ask the client to read messages on a whiteboard
Correct Answer:
- Provide pictures to help the client understand
1) Expressive aphasia-> referred to Broca, or motor, aphasia- difficulty speaking, difficulty writing 2) Receptive aphasia-> referred to as Wernicke, or sensory, aphasia- difficulty understanding spoken words- difficulty understanding written words- speech often meaningless- made-up words
A client returns from the postanesthesia care unit (PACU) after a surgical removal of a frontal lobe tumor. In what position will the nurse place the client at this time?
- Turn the client from side to side to prevent aspiration.
- Elevate the head of the bed to at least 30 degrees at all times.
- Keep the client flat in bed or up 10 degrees and reposition from side to side
- Keep the client in a high-fowler position in bed at all times
Correct Answer:
- Elevate the head of the bed to at least 30 degrees at all times.
A client comes in with suspected heat stroke, what are some symptoms the nurse should expect?(select all that apply)
- Body temperature above 104F
- Pulmonary edema
- Hypertension
- Tachycardia
- Tachypnea
- Oliguria 3 / 4
- Hallucinations
- Memory loss
Correct Answer:
- Body temperature above 104F
- Pulmonary edema
- Tachycardia
- Tachypnea
- Oliguria
- Hallucinations
- Memory Loss
Treatments for Heat stroke?
Correct Answer:
1) Oxygen therapy 2) urinary catheter 3) continuous cooling until body temperature is 102F or below 4) If shivering occurs (Benzodiazepines--> Propofol (can cause hypotension), Midazolam (puts the patient at risk for delirium)
What are the body temperatures for mild, moderate, and severe hypothermia?
Correct Answer:
Mild: 95-90
Moderate: 90-82
Severe: Below 82
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