NURS3710 MedSurg Practice Questions Exam
With Complete Solutions
The nurse is caring for a client with a neck fracture at the C5 level in the intensive care
unit. During initial assessment of the client, the nurse recognizes the presence of
neurogenic shock upon assessing which of the following findings?
a. Hypotension, bradycardia, and warm extremities
b. Involuntary, spastic movements of the arms and legs
c. Hyperactive reflex activity below the level of the injury
d. Lack of movement or sensation below the level of the injury - ANSWER a.
Hypotension, bradycardia, and warm extremities
ANS: A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation
leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at
this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord
injury, but not neurogenic shock.
The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit.
Which of the following information should the nurse include in the teaching plan for the
client and family?
a. Use of the shoulders will be preserved.
b. Full function of the client's arms will be retained.
c. Total loss of respiratory function may occur temporarily.
d. Elevations in heart rate are common with this type of injury. - ANSWER b. Full function
of the client's arms will be retained.
ANS: B
The client with a T1 injury can expect to retain full motor and sensory function of the
arms. Use of only the shoulders is associated with cervical spine injury. Loss of
respiratory function occurs with cervical spine injuries. Bradycardia is associated with
,injuries above
the T6 level.
The nurse is caring for a client with paraplegia resulting from a T10 spinal cord injury
who has a neurogenic reflex bladder. Which of the following actions should the nurse
include in the plan of care?
a. Educate on the use of the Credé method.
b. Teach the client how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the client to the toilet every 2 hours. - ANSWER b. Teach the client how to
self-catheterize.
ANS: B
Because the client's bladder is spastic and will empty in response to overstretching of
the bladder wall, the most appropriate method is to avoid incontinence by emptying the
bladder at regular intervals through intermittent catheterization. Assisting the client to
the
toilet will not be helpful because the bladder will not empty. The Credé method is more
appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic
bladder. Catheterization after voiding will not resolve the client's incontinence.
The nurse is developing a rehabilitation plan for a client with a C6 spinal cord injury.
Which of the following goals should the nurse include for this client?
a. Transfer independently to a wheelchair.
b. Drive a car with powered hand controls.
c. Turn and reposition independently when in bed.
d. Push a manual wheelchair on flat, smooth surfaces. - ANSWER d. Push a manual
wheelchair on flat, smooth surfaces.
ANS: D
The client with a C6 injury will be able to use the hands to push a wheelchair on flat,
, smooth surfaces. Because flexion of the thumb and fingers is minimal, the client will not
be able to grasp a wheelchair during transfer, drive a car with powered hand controls,
or turn independently in bed.
The nurse is caring for a client who sustained a spinal cord injury a week ago and
becomes angry, telling the nurse "I want to be transferred to a hospital where the
nurses know what they are doing!" Which of the following actions by the nurse is best?
a. Ask for the client's input into the plan for care.
b. Clarify that abusive behaviour will not be tolerated.
c. Reassure the client about the competence of the nursing staff.
d. Continue to perform care without responding to the client's comments. - ANSWER a.
Ask for the client's input into the plan for care.
ANS: A
The client is demonstrating behaviours consistent with the anger phase of the mourning
process, and the nurse should allow expression of anger and seek the client's input into
care. Expression of anger is appropriate at this stage and should be tolerated by the
nurse.
Reassurance about the competency of the staff will not be helpful in responding to the
client's anger. Ignoring the client's comments will increase the client's anger and sense
of helplessness.
After a young adult client has returned home following rehabilitation for a spinal cord
injury, the home care nurse notes that the partner is performing many of the activities
that the client had been managing during rehabilitation. Which of the following actions
by the
nurse is most appropriate at this time?
a. Tell the partner that the client can perform activities independently.
b. Remind the client about the importance of independence in daily activities.
c. Develop a plan to increase the client's independence in consultation with the client
and the partner.
d. Recognize that it is important for the partner to be involved in the client's care and
support the partner's participation. - ANSWER c. Develop a plan to increase the client's
With Complete Solutions
The nurse is caring for a client with a neck fracture at the C5 level in the intensive care
unit. During initial assessment of the client, the nurse recognizes the presence of
neurogenic shock upon assessing which of the following findings?
a. Hypotension, bradycardia, and warm extremities
b. Involuntary, spastic movements of the arms and legs
c. Hyperactive reflex activity below the level of the injury
d. Lack of movement or sensation below the level of the injury - ANSWER a.
Hypotension, bradycardia, and warm extremities
ANS: A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation
leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at
this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord
injury, but not neurogenic shock.
The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit.
Which of the following information should the nurse include in the teaching plan for the
client and family?
a. Use of the shoulders will be preserved.
b. Full function of the client's arms will be retained.
c. Total loss of respiratory function may occur temporarily.
d. Elevations in heart rate are common with this type of injury. - ANSWER b. Full function
of the client's arms will be retained.
ANS: B
The client with a T1 injury can expect to retain full motor and sensory function of the
arms. Use of only the shoulders is associated with cervical spine injury. Loss of
respiratory function occurs with cervical spine injuries. Bradycardia is associated with
,injuries above
the T6 level.
The nurse is caring for a client with paraplegia resulting from a T10 spinal cord injury
who has a neurogenic reflex bladder. Which of the following actions should the nurse
include in the plan of care?
a. Educate on the use of the Credé method.
b. Teach the client how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the client to the toilet every 2 hours. - ANSWER b. Teach the client how to
self-catheterize.
ANS: B
Because the client's bladder is spastic and will empty in response to overstretching of
the bladder wall, the most appropriate method is to avoid incontinence by emptying the
bladder at regular intervals through intermittent catheterization. Assisting the client to
the
toilet will not be helpful because the bladder will not empty. The Credé method is more
appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic
bladder. Catheterization after voiding will not resolve the client's incontinence.
The nurse is developing a rehabilitation plan for a client with a C6 spinal cord injury.
Which of the following goals should the nurse include for this client?
a. Transfer independently to a wheelchair.
b. Drive a car with powered hand controls.
c. Turn and reposition independently when in bed.
d. Push a manual wheelchair on flat, smooth surfaces. - ANSWER d. Push a manual
wheelchair on flat, smooth surfaces.
ANS: D
The client with a C6 injury will be able to use the hands to push a wheelchair on flat,
, smooth surfaces. Because flexion of the thumb and fingers is minimal, the client will not
be able to grasp a wheelchair during transfer, drive a car with powered hand controls,
or turn independently in bed.
The nurse is caring for a client who sustained a spinal cord injury a week ago and
becomes angry, telling the nurse "I want to be transferred to a hospital where the
nurses know what they are doing!" Which of the following actions by the nurse is best?
a. Ask for the client's input into the plan for care.
b. Clarify that abusive behaviour will not be tolerated.
c. Reassure the client about the competence of the nursing staff.
d. Continue to perform care without responding to the client's comments. - ANSWER a.
Ask for the client's input into the plan for care.
ANS: A
The client is demonstrating behaviours consistent with the anger phase of the mourning
process, and the nurse should allow expression of anger and seek the client's input into
care. Expression of anger is appropriate at this stage and should be tolerated by the
nurse.
Reassurance about the competency of the staff will not be helpful in responding to the
client's anger. Ignoring the client's comments will increase the client's anger and sense
of helplessness.
After a young adult client has returned home following rehabilitation for a spinal cord
injury, the home care nurse notes that the partner is performing many of the activities
that the client had been managing during rehabilitation. Which of the following actions
by the
nurse is most appropriate at this time?
a. Tell the partner that the client can perform activities independently.
b. Remind the client about the importance of independence in daily activities.
c. Develop a plan to increase the client's independence in consultation with the client
and the partner.
d. Recognize that it is important for the partner to be involved in the client's care and
support the partner's participation. - ANSWER c. Develop a plan to increase the client's
