ATI MEDSURG 2 NUR 265/DETAILED ANSWER
KEY NEURO-SHOCK & BURNS PRACTICE
1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical
cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.)
A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex
Rationale: <b>Hypotension is correct.</b> Lack of sympathetic input can cause a decrease in blood pressure.
The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal
cord.</br></br><b>Polyuria is incorrect.</b> The nurse should check the client for bladder
distention and inability to urinate due to ineffective function of the bladder
muscles.</br></br><b>Hyperthermia is incorrect.</b> The nurse should monitor the client for
hypothermia caused by a lack of lack of sympathetic input.</br></br><b>Absence of bowel sounds
is correct.</b> Spinal shock leads to decreased peristalsis, which could cause the client to develop
a paralytic ileus.</br></br><b>Weakened gag reflex is correct.</b> The nurse should monitor the
client for difficulty swallowing, or coughing and drooling noted with oral intake.
2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of
the following statements by the client indicates a need for further teaching?
A. "I will notify my doctor before taking any other medications."
Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should be
notified that the client is taking phenytoin.
B. "I have made an appointment to see my dentist next week."
Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dental
monitoring important.
C. "I know that I cannot switch brands of this medication."
Rationale: The client understands that bioavailability varies with different brands, so no substitutions should
be made.
,Detailed Answer Key
Neuro-Shock & Burns practice
D. "I'll be glad when I can stop taking this medicine."
Rationale: Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant
medications commonly require them for lifetime administration, and phenytoin should not be
stopped without the advice of the client's provider.
3. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription
for timolol eye drops. Which of the following instructions should the nurse provide?
A. The medication is to be applied when the client is experiencing eye pain.
Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserve remaining
eyesight.
B. The medication will be used until the client's intraocular pressure returns to normal.
Rationale: Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen the
client's condition.
C. The medication should be applied on a regular schedule for the rest of the client's life.
Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or
decrease its production, or both. The client must continue the eye drops on an uninterrupted basis
for life to maintain intraocular pressure at an acceptable level.
D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.
Rationale: Treatment for open-angle glaucoma is to continue for life.
4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should
the nurse take first?
A. Turn the client's head to the side.
Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
B. Check the client's motor strength.
Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment following
the seizure; however, there is another action the nurse should take first.
C. Loosen the clothing around the client's waist.
,Detailed Answer Key
Neuro-Shock & Burns practice
Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;
however, there is another action the nurse should take first.
D. Document the time the seizure began.
Rationale: The nurse should document the time the seizure began and ended to provide information to the
provider about the severity of the seizure; however, there is another action the nurse should take
first.
5. A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the
nurse report to the client's provider?
A. "My eye really itches, but I'm trying not to rub it." Rationale:
Itching is common after cataract surgery. The nurse should remind the client not to rub or place
pressure on the eyes.
B. "I need something for the pain in my eye. I can't stand it."
Rationale: Following cataract surgery, the client should expect only mild pain and should immediately report
any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery
might indicate increased intraocular pressure or hemorrhage.
C. "It's hard to see with a patch on one eye. I'm afraid of falling."
Rationale: Clients who wear an eye patch lose their depth perception and part of their peripheral vision,
temporarily decreasing visual acuity.
D. "The bright light in this room is really bothering me."
Rationale: The client may find that exposure to bright light is uncomfortable after cataract surgery. Wearing
sunglasses can prevent most of the client's discomfort.
, Detailed Answer Key
Neuro-Shock & Burns practice
6. A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing
the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should
be the nurse’s initial action?
A. Document the amount of drainage.
Rationale: The nurse should document the amount of drainage along with the clarity to determine the
extent of the cerebral spinal fluid (CSF) leakage and the presence of blood or pus; however
there is another action that is priority.
B. Obtain a culture of the drainage.
Rationale: Although infection is a potential complication of the procedure, there is another action that is
priority.
C. Check the drainage for glucose.
Rationale: A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage
from the nose is a sign that this complication has occurred. The first action the nurse should take
using the nursing process is to assess the drainage for the presence of glucose, which would indicate
that the drainage is CSF.
D. Notify the client's provider.
Rationale: Although the provider should be notified of the findings, there is another action that is priority.
7. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the
following parameters should the nurse use first in order to assess the client's pain level?
A. pulse and blood pressure findings
Rationale: The nurse should assess the client's pain level routinely along with vital signs. A pain
KEY NEURO-SHOCK & BURNS PRACTICE
1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical
cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.)
A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex
Rationale: <b>Hypotension is correct.</b> Lack of sympathetic input can cause a decrease in blood pressure.
The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal
cord.</br></br><b>Polyuria is incorrect.</b> The nurse should check the client for bladder
distention and inability to urinate due to ineffective function of the bladder
muscles.</br></br><b>Hyperthermia is incorrect.</b> The nurse should monitor the client for
hypothermia caused by a lack of lack of sympathetic input.</br></br><b>Absence of bowel sounds
is correct.</b> Spinal shock leads to decreased peristalsis, which could cause the client to develop
a paralytic ileus.</br></br><b>Weakened gag reflex is correct.</b> The nurse should monitor the
client for difficulty swallowing, or coughing and drooling noted with oral intake.
2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of
the following statements by the client indicates a need for further teaching?
A. "I will notify my doctor before taking any other medications."
Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should be
notified that the client is taking phenytoin.
B. "I have made an appointment to see my dentist next week."
Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dental
monitoring important.
C. "I know that I cannot switch brands of this medication."
Rationale: The client understands that bioavailability varies with different brands, so no substitutions should
be made.
,Detailed Answer Key
Neuro-Shock & Burns practice
D. "I'll be glad when I can stop taking this medicine."
Rationale: Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant
medications commonly require them for lifetime administration, and phenytoin should not be
stopped without the advice of the client's provider.
3. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription
for timolol eye drops. Which of the following instructions should the nurse provide?
A. The medication is to be applied when the client is experiencing eye pain.
Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserve remaining
eyesight.
B. The medication will be used until the client's intraocular pressure returns to normal.
Rationale: Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen the
client's condition.
C. The medication should be applied on a regular schedule for the rest of the client's life.
Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or
decrease its production, or both. The client must continue the eye drops on an uninterrupted basis
for life to maintain intraocular pressure at an acceptable level.
D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.
Rationale: Treatment for open-angle glaucoma is to continue for life.
4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should
the nurse take first?
A. Turn the client's head to the side.
Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
B. Check the client's motor strength.
Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment following
the seizure; however, there is another action the nurse should take first.
C. Loosen the clothing around the client's waist.
,Detailed Answer Key
Neuro-Shock & Burns practice
Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;
however, there is another action the nurse should take first.
D. Document the time the seizure began.
Rationale: The nurse should document the time the seizure began and ended to provide information to the
provider about the severity of the seizure; however, there is another action the nurse should take
first.
5. A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the
nurse report to the client's provider?
A. "My eye really itches, but I'm trying not to rub it." Rationale:
Itching is common after cataract surgery. The nurse should remind the client not to rub or place
pressure on the eyes.
B. "I need something for the pain in my eye. I can't stand it."
Rationale: Following cataract surgery, the client should expect only mild pain and should immediately report
any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery
might indicate increased intraocular pressure or hemorrhage.
C. "It's hard to see with a patch on one eye. I'm afraid of falling."
Rationale: Clients who wear an eye patch lose their depth perception and part of their peripheral vision,
temporarily decreasing visual acuity.
D. "The bright light in this room is really bothering me."
Rationale: The client may find that exposure to bright light is uncomfortable after cataract surgery. Wearing
sunglasses can prevent most of the client's discomfort.
, Detailed Answer Key
Neuro-Shock & Burns practice
6. A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing
the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should
be the nurse’s initial action?
A. Document the amount of drainage.
Rationale: The nurse should document the amount of drainage along with the clarity to determine the
extent of the cerebral spinal fluid (CSF) leakage and the presence of blood or pus; however
there is another action that is priority.
B. Obtain a culture of the drainage.
Rationale: Although infection is a potential complication of the procedure, there is another action that is
priority.
C. Check the drainage for glucose.
Rationale: A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage
from the nose is a sign that this complication has occurred. The first action the nurse should take
using the nursing process is to assess the drainage for the presence of glucose, which would indicate
that the drainage is CSF.
D. Notify the client's provider.
Rationale: Although the provider should be notified of the findings, there is another action that is priority.
7. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the
following parameters should the nurse use first in order to assess the client's pain level?
A. pulse and blood pressure findings
Rationale: The nurse should assess the client's pain level routinely along with vital signs. A pain
