NURS 423 Exam 4 Questions and Answers with 100% Correct Answers
Already Graded A+
When caring for a patient who has admitted was admitted 24 hours previously with a C5 spinal cord
injury, which nursing action has the highest priority?
1. Continuous cardiac monitoring for bradycardia
2. Administration of methylprednisolone infusion
3. Assessment of respiratory rate and depth
4. Application of pneumatic compression devices to both legs - (ANSWER)3. Assessment of respiratory
rate and depth
The nurses caring for a patient who sustained a spinal cord injury during administration of morning care
the patient begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action
should the nurse take?
1. elevate the head of the bed
2. check the pmts urinary catheter for kinking
3. assess the pmts blood pressure
4. place the pt in the prone position - (ANSWER)1. elevate the head of the bed
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of
the following findings, its utmost concern to the nurse?
1. SpO2 of 92%
2. HR of 42bpm
3. BP of 112/70
4. Loss of motor and sensory function in the arms and legs - (ANSWER)2. HR of 42bpm
In assessing a patient with a teeth 12 spinal cord injury which clinical manifestations with the nurse
expect to find to support the diagnosis of spinal shock?
1. Inability to move upper extremities
2. No reflex activity below the waist
3. Complaints of a pounding headache
4. Hypotension and bradycardia - (ANSWER)2. No reflex activity below the waist
,NURS 423 Exam 4 Questions and Answers with 100% Correct Answers
Already Graded A+
A patient is being evaluated to rule out Myasthenia Gravis, and it's being administered the tensilon test.
Which response to the test indicates the patient has Myasthenia gravis?
1. The pt has no apparent change in the assessment data
2. There is increased amplitude of electrical stimulation in the muscles
3. The circulating acetylcholine receptor antibodies are decreased
4. The pt shows a marked improvement of muscle strength - (ANSWER)4. The pt shows a marked
improvement of muscle strength
The nurses caring for a patient who has been recently diagnosed with Myasthenia Gravis. The nurse
should teach the patient that Myasthenia Gravis is caused by?
1. Amyloid plaques and neurofibrillary tangles
2. Destruction of acetylcholine receptors
3. Degeneration of dopamine-producing neurons in the basal ganglia
4. Demyelination of nerve fibers in the brain and spinal cord - (ANSWER)2. Destruction of acetylcholine
receptors
When planning care for the patient with trigeminal neuralgia which patient outcome should the nurse
set as the highest priority?
1. Maintenance of positive body image
2. Protection of the cornea
3. Relief of pain
4. Maintenance of nutrition - (ANSWER)3. Relief of pain
The nurse is performing an assessment on a patient with the diagnosis of Bell's palsy. The nurse should
expect to observe which finding in the patient?
1. Periorbital edema
2. Facial drooping
3. Prosis of the eyelid
, NURS 423 Exam 4 Questions and Answers with 100% Correct Answers
Already Graded A+
4. Twitching on the affected side of the face - (ANSWER)2. Facial drooping
A 24 year old pt is hospitalized with the onset of Guillain-Barre syndrome. During this phase of the
patient's illness, the most essential assessment for the nurse to carry out is?
1. Monitoring the cardiac rhythm continuously
2. Determining the level of consciousness every 2 hours
3. Evaluating sensation and strength of the extremities
4. Performing constant evaluation of respiratory function - (ANSWER)4. Performing constant evaluation
of respiratory function
The patient diagnosed with Guillain-Barre syndrome asks the nurse, "Will I ever get back to normal? I am
so tired of being sick." Which statement is the best response by the nurse?
1. You should make a full recovery within a few months to a year.
2. Most its with this syndrome have some type of residual disability.
3. This is something you should discuss with the healthcare team.
4. The rehab is short and you should be fully recovered within a month. - (ANSWER)1. You should make a
full recovery within a few months to a year.
Which assessment date would make the nurse suspect the patient has ALS?
1. History of a cold or vaccination within the last month
2. Complaints of double vision and drooping eyelids
3. Fatigue, progressive muscle weakness, twitching
4. Loss of sensation below the level of the umbilicus - (ANSWER)3. Fatigue, progressive muscle
weakness, twitching
A 72 year old patient hospitalized with pneumonia is disoriented and confused 2 days after admission.
Which assessment information obtained by the nurse about the patient indicates that the patient is
experiencing delirium, rather than dementia?
1. The pt is disoriented to place and time but oriented to person
Already Graded A+
When caring for a patient who has admitted was admitted 24 hours previously with a C5 spinal cord
injury, which nursing action has the highest priority?
1. Continuous cardiac monitoring for bradycardia
2. Administration of methylprednisolone infusion
3. Assessment of respiratory rate and depth
4. Application of pneumatic compression devices to both legs - (ANSWER)3. Assessment of respiratory
rate and depth
The nurses caring for a patient who sustained a spinal cord injury during administration of morning care
the patient begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action
should the nurse take?
1. elevate the head of the bed
2. check the pmts urinary catheter for kinking
3. assess the pmts blood pressure
4. place the pt in the prone position - (ANSWER)1. elevate the head of the bed
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of
the following findings, its utmost concern to the nurse?
1. SpO2 of 92%
2. HR of 42bpm
3. BP of 112/70
4. Loss of motor and sensory function in the arms and legs - (ANSWER)2. HR of 42bpm
In assessing a patient with a teeth 12 spinal cord injury which clinical manifestations with the nurse
expect to find to support the diagnosis of spinal shock?
1. Inability to move upper extremities
2. No reflex activity below the waist
3. Complaints of a pounding headache
4. Hypotension and bradycardia - (ANSWER)2. No reflex activity below the waist
,NURS 423 Exam 4 Questions and Answers with 100% Correct Answers
Already Graded A+
A patient is being evaluated to rule out Myasthenia Gravis, and it's being administered the tensilon test.
Which response to the test indicates the patient has Myasthenia gravis?
1. The pt has no apparent change in the assessment data
2. There is increased amplitude of electrical stimulation in the muscles
3. The circulating acetylcholine receptor antibodies are decreased
4. The pt shows a marked improvement of muscle strength - (ANSWER)4. The pt shows a marked
improvement of muscle strength
The nurses caring for a patient who has been recently diagnosed with Myasthenia Gravis. The nurse
should teach the patient that Myasthenia Gravis is caused by?
1. Amyloid plaques and neurofibrillary tangles
2. Destruction of acetylcholine receptors
3. Degeneration of dopamine-producing neurons in the basal ganglia
4. Demyelination of nerve fibers in the brain and spinal cord - (ANSWER)2. Destruction of acetylcholine
receptors
When planning care for the patient with trigeminal neuralgia which patient outcome should the nurse
set as the highest priority?
1. Maintenance of positive body image
2. Protection of the cornea
3. Relief of pain
4. Maintenance of nutrition - (ANSWER)3. Relief of pain
The nurse is performing an assessment on a patient with the diagnosis of Bell's palsy. The nurse should
expect to observe which finding in the patient?
1. Periorbital edema
2. Facial drooping
3. Prosis of the eyelid
, NURS 423 Exam 4 Questions and Answers with 100% Correct Answers
Already Graded A+
4. Twitching on the affected side of the face - (ANSWER)2. Facial drooping
A 24 year old pt is hospitalized with the onset of Guillain-Barre syndrome. During this phase of the
patient's illness, the most essential assessment for the nurse to carry out is?
1. Monitoring the cardiac rhythm continuously
2. Determining the level of consciousness every 2 hours
3. Evaluating sensation and strength of the extremities
4. Performing constant evaluation of respiratory function - (ANSWER)4. Performing constant evaluation
of respiratory function
The patient diagnosed with Guillain-Barre syndrome asks the nurse, "Will I ever get back to normal? I am
so tired of being sick." Which statement is the best response by the nurse?
1. You should make a full recovery within a few months to a year.
2. Most its with this syndrome have some type of residual disability.
3. This is something you should discuss with the healthcare team.
4. The rehab is short and you should be fully recovered within a month. - (ANSWER)1. You should make a
full recovery within a few months to a year.
Which assessment date would make the nurse suspect the patient has ALS?
1. History of a cold or vaccination within the last month
2. Complaints of double vision and drooping eyelids
3. Fatigue, progressive muscle weakness, twitching
4. Loss of sensation below the level of the umbilicus - (ANSWER)3. Fatigue, progressive muscle
weakness, twitching
A 72 year old patient hospitalized with pneumonia is disoriented and confused 2 days after admission.
Which assessment information obtained by the nurse about the patient indicates that the patient is
experiencing delirium, rather than dementia?
1. The pt is disoriented to place and time but oriented to person
