TDLR Esthetician State Board Review Revised Questions and Answers / Sure A+ ( SKINCARE)

MedSurg Neurological Disorders NCLEX Revised Questions and Answers / Sure A + A 22 -year -old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed. B. Assess patency of the indwelling urinary catheter. C. Give one SL nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees. - D. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note : Placing tetraplegic in sitting position automatically lowers BP . A 23 -year -old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A. Position the client flat in bed. B. Check the fluid for dextrose with a dipstick. C. Suction the nose to maintain airway patency. D. Insert nasal and ear packing with sterile gauze. - B. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. CSF Leak is a condition in which CSF is able to escape from the subarachnoid space through a hole in the surrounding dura. The volume of C SF lost in a leak is very variable, ranging from insignificant to very substantial amounts. A 30 -year -old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury - C. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications. A 78 -year -old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt -PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation. - C. A CT scan will determine if the client is having a stroke or has a brain tumour or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use tPA. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstanc es? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF). - B. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favours herniation of the brain; therefore, LP is contraindicated with increased ICP . A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t -PA) administration. Which is the priority nursing assessment? A. Time of onset of current stroke B. Complete physical and history C. Current medications D. Upcoming surgical procedures - A. The time of onset of a stroke to t -PA administration is critical. Administration within 3 hours has better outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes that cleave peptide bonds in proteins). It is thus one of th e essential components of the dissolution of blood clots. Its primary function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in dissolving blood clots. A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x -ray. C. Immobilize the client's head and neck. D. Open the airway with the head -tilt-chin -lift maneuver. - C. All clients with a head injury are treated as if a cervical spine injury is present until x -rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. The management of patients with hea d trauma should always consider C -spine motion restriction. Hold the neck immobile in line with the body, apply a rigid or semi rigid cervical collar, and (unless the patient is very restless) secure the head to the trolley with sandbags and tape. A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive - C. The client is experiencing an autonomic dysreflexia, a life -threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is s uspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke. A client is admitted with a diagnosis of Sturge -Weber syndrome. Which of the following information would you expect to find in this client? A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or across the cheeks. B. It is a non -progressive neurological disorder of the seventh cranial nerve causing paralysis of one of the sides of the face. C. It is a rare degenerative brain disorder characterized by sudden development of progressive neurological and neuromuscular symptoms. D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth. - D. Sturge -Weber syndrome, also known as encephalofacial or encephalotrigeminal angiomatosis, is a neurocutaneous syndrome that is associated with a port -wine birthmark (facial port -wine stains in the trigeminal nerve distribution), vascular lesions in the ips ilateral brain and meninges, and eye problems such as glaucoma. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. acetazolamide (Diamox) B. furosemide (Lasix) C. methylprednisolone (Solu -Medrol) D. sodium bicarbonate - C. High doses of Solu -Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Methylprednisolone and its derivatives, methylprednisolone acetate succinate, and methylprednisolone sodium, are intermediate -acting, synthetic glucocorticoids used mainly as anti -inflammatory or immunosuppressive agents. Methylprednisolone is five times more potent in its anti -inflammatory properties relative to hydrocortisone (co rtisol), with minimal mineralocorticoid activities compared to the latter. A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: