NUR 405 Final Exam practice questions with
complete solutions
In |assessing |a |client |with |a |Thoracic |SCI, |which |clinical |manifestation |would |the |nurse |expect |
to |find |to |support |the |diagnosis |of |neurogenic |shock?
A. |No |reflex |activity |below |the |waist.
B. |Inability |to |move |upper |extremities.
C. |Complaints |of |a |pounding |headache.
D. |Hypertension |and |tachycardia.
A. |No |reflex |activity |below |the |waist.
Rationale:
Neurogenic |shock |associated |with |SCI |represents |a |sudden |depression |of |reflex |activity |below |
the |level |of |the |injury.TI2 |is |just |above |the |waist; |therefore, |no |reflex |activity |below |the |waist |
would |be |expected.
TEST |TAKING |HINT: |If |the |test |taker |does |not |have |any |idea |what |the |answer |is, |an |attempt |to
|relate |the |anatomical |position |of |keywords |in |the |question |stem |to |words |in |the |answer |
options |is |appropriate. |In |this |case, |T12, |mentioned |in |the |stem, |is |around |the |waist, |so |
answer |options |involving |the |anatomy |above |that |level |(e.g., |the |upper |extremities) |can |be |
eliminated.
The |nurse |in |the |neurointensive |care |unit |is |caring |for |a |client |with |a |new |Cervical |SCI |who |is |
breathing |independently. |Which |nursing |interventions |should |be |implemented? |Select |all |that |
apply.
A. |Monitor |the |pulse |oximetry |reading.
B. |Provide |pureed |foods |six |(6) |times |a |day.
C. |Encourage |coughing |and |deep |breathing.
D. |Assess |for |autonomic |dysreflexia.
E. |Administer |intravenous |corticosteroids.
A. |Monitor |the |pulse |oximetry |reading.
,C. |Encourage |coughing |and |deep |breathing.
E. |Administer |intravenous |corticosteroids.
Rationale:
A) |Oxygen |is |administered |initially |to |prevent |hypoxemia, |which |can |worsen |the |spinal |cord |
injury; |therefore, |the |nurse |should |determine |how |much |oxygen |is |reaching |the |periphery.
B) |A |C6 |injury |would |not |affect |the |client's |ability |to |chew |and |swallow, |so |pureed |food |is |not |
necessary.
C) |Breathing |exercises |are |supervised |by |the |nurse |to |increase |the |strength |and |endurance |
of |inspiratory |muscles, |especially |those |of |the |diaphragm.
D) |Autonomic |dysreflexia |occurs |during |the |rehabilitation |phase, |not |the |acute |phase.
E) |Corticosteroids |are |administered |to |decrease |inflammation, |which |will |decrease |edema, |
and |help |prevent |edema |from |ascending |up |the |spinal |cord, |causing |breathing |difficulties.
TEST |TAKING |HINT: |The |test |taker |must |notice |where |the |client |is |receiving |care, |which |may |
be |instrumental |in |being |able |to |rule |out |incorrect |answer |options |and |help |in |identifying |the |
correct |answer. |Remember |Maslow's |hierarchy |of |needs- |oxygen |and |breathing |are |priority |
nursing |interventions.
The |client |with |a |C6 |SCI |is |admitted |to |the |emergency |department |complaining |of |a |severe |
pounding |headache |and |has |a |BP |of |180/110. |Which |intervention |should |the |emergency |
department |nurse |implement?
A. |Keep |the |client |flat |in |bed.
B. |Dim |the |lights |in |the |room.
C. |Assess |for |bladder |distention.
D. |Administer |a |narcotic |analgesic.
C. |Assess |for |bladder |distention.
Rationale:
This |is |an |acute |emergency |caused |by |exaggerated |autonomic |responses |to |stimuli |and |only |
occurs |after |spinal |shock |has |resolved |in |the |client |with |a |spinal |cord |injury |above |T6. |The |
most |common |cause |is |a |full |bladder.
TEST |TAKING |HINT: |The |test |taker |should |apply |the |nursing |process |when |answering |
questions, |and |assessing |the |client |comes |first, |before |administering |any |type |of |medication.
,We |have |an |expert-written |solution |to |this |problem!
The |34-year-old |male |client |with |an |SCI |is |sharing |with |the |nurse |that |he |is |worried |about |
finding |employment |after |being |discharged |from |the |rehabilitation |unit. |Which |intervention |
should |the |nurse |implement?
A. |Refer |the |client |to |the |American |Spinal |Cord |Injury |Association |(ASIA).
B. |Refer |the |client |to |the |state |rehabilitation |commission.
C. |Ask |the |social |worker |(SW) |about |applying |for |disability.
D. |Suggest |that |the |client |talk |with |his |significant |other |about |this |concern.
B. |Refer |the |client |to |the |state |rehabilitation |commission.
Rationale:
The |rehabilitation |commission |of |each |state |will |help |evaluate |and |determine |if |the |client |can |
receive |training |or |education |for |another |occupation |after |injury.
TEST |TAKING |HINT: |If |the |question |mentions |a |specific |age |for |a |client, |the |nurse |should |
consider |it |when |attempting |to |answer |the |question. |This |is |a |young |person |who |needs |to |find
|gainful |employment. |Remember |Erickson's |stages |of |growth |and |development.
We |have |an |expert-written |solution |to |this |problem!
The |nurse |is |conducting |a |support |group |for |clients |diagnosed |with |Parkinson's |disease |and |
their |significant |others. |Which |information |regarding |psychosocial |needs |should |be |included |in
|the |discussion?
A. |The |client |should |discuss |feelings |about |being |placed |on |a |ventilator.
B. |The |client |may |have |rapid |mood |swings |and |become |easily |upset.
C. |Pill-rolling |tremors |will |become |worse |when |the |medication |is |wearing |off.
D. |The |client |may |automatically |start |to |repeat |what |another |person |says.
B. |The |client |may |have |rapid |mood |swings |and |become |easily |upset.
Rationale:
These |are |psychosocial |manifestations |ofPD. |These |should |be |discussed |in |the |support |
meeting.
, TEST |TAKING |HINT: |Psychosocial |problems |should |address |the |client's |feelings |or |interactions |
with |another |person.
We |have |an |expert-written |solution |to |this |problem!
The |nurse |is |caring |for |clients |on |a |medical-surgical |floor. |Which |clients |should |be |assessed |
first?
A. |The |65-year-old |client |diagnosed |with |seizures |who |is |complaining |of |a |headache |that |is |a
|"2" |on |a |1-to-10 |scale.
B. |The |24-year-old |client |diagnosed |with |a |T10 |spinal |cord |injury |who |cannot |move |his |toes.
C. |The |58-year-old |client |diagnosed |with |Parkinson's |disease |who |is |crying |and |worried |about |
her |facial |appearance.
D. |The |62-year-old |client |diagnosed |with |a |cerebrovascular |accident |who |has |a |resolving |left |
hemiparesis.
C. |The |58-year-old |client |diagnosed |with |Parkinson's |disease |who |is |crying |and |worried |about |
her |facial |appearance.
Rationale:
Body |image |is |a |concern |for |clients |diagnosed |with |PD. |This |client |is |the |one |client |who |is |not |
experiencing |expected |sequelae |of |the |disease.
TEST |TAKING |HINT:
At |times |a |psychological |problem |can |have |priority. |All |the |physical |problems |are |expected |and
|are |not |life |threatening |or |life |altering.
The |male |client |diagnosed |with |CKD |has |received |the |initial |dose |of |erythropoietin, |a |biologic |
response |modifier, |one |(1) |week |ago. |Which |complaint |by |the |client |indicates |the |need |to |
notify |the |health-care |provider?
A. |The |client |complains |of |flu-like |symptoms.
B. |The |client |complains |of |being |tired |all |the |time.
C. |The |client |reports |an |elevation |in |his |blood |pressure.
D. |The |client |reports |discomfort |in |his |legs |and |back.
C. |The |client |reports |an |elevation |in |his |blood |pressure.
complete solutions
In |assessing |a |client |with |a |Thoracic |SCI, |which |clinical |manifestation |would |the |nurse |expect |
to |find |to |support |the |diagnosis |of |neurogenic |shock?
A. |No |reflex |activity |below |the |waist.
B. |Inability |to |move |upper |extremities.
C. |Complaints |of |a |pounding |headache.
D. |Hypertension |and |tachycardia.
A. |No |reflex |activity |below |the |waist.
Rationale:
Neurogenic |shock |associated |with |SCI |represents |a |sudden |depression |of |reflex |activity |below |
the |level |of |the |injury.TI2 |is |just |above |the |waist; |therefore, |no |reflex |activity |below |the |waist |
would |be |expected.
TEST |TAKING |HINT: |If |the |test |taker |does |not |have |any |idea |what |the |answer |is, |an |attempt |to
|relate |the |anatomical |position |of |keywords |in |the |question |stem |to |words |in |the |answer |
options |is |appropriate. |In |this |case, |T12, |mentioned |in |the |stem, |is |around |the |waist, |so |
answer |options |involving |the |anatomy |above |that |level |(e.g., |the |upper |extremities) |can |be |
eliminated.
The |nurse |in |the |neurointensive |care |unit |is |caring |for |a |client |with |a |new |Cervical |SCI |who |is |
breathing |independently. |Which |nursing |interventions |should |be |implemented? |Select |all |that |
apply.
A. |Monitor |the |pulse |oximetry |reading.
B. |Provide |pureed |foods |six |(6) |times |a |day.
C. |Encourage |coughing |and |deep |breathing.
D. |Assess |for |autonomic |dysreflexia.
E. |Administer |intravenous |corticosteroids.
A. |Monitor |the |pulse |oximetry |reading.
,C. |Encourage |coughing |and |deep |breathing.
E. |Administer |intravenous |corticosteroids.
Rationale:
A) |Oxygen |is |administered |initially |to |prevent |hypoxemia, |which |can |worsen |the |spinal |cord |
injury; |therefore, |the |nurse |should |determine |how |much |oxygen |is |reaching |the |periphery.
B) |A |C6 |injury |would |not |affect |the |client's |ability |to |chew |and |swallow, |so |pureed |food |is |not |
necessary.
C) |Breathing |exercises |are |supervised |by |the |nurse |to |increase |the |strength |and |endurance |
of |inspiratory |muscles, |especially |those |of |the |diaphragm.
D) |Autonomic |dysreflexia |occurs |during |the |rehabilitation |phase, |not |the |acute |phase.
E) |Corticosteroids |are |administered |to |decrease |inflammation, |which |will |decrease |edema, |
and |help |prevent |edema |from |ascending |up |the |spinal |cord, |causing |breathing |difficulties.
TEST |TAKING |HINT: |The |test |taker |must |notice |where |the |client |is |receiving |care, |which |may |
be |instrumental |in |being |able |to |rule |out |incorrect |answer |options |and |help |in |identifying |the |
correct |answer. |Remember |Maslow's |hierarchy |of |needs- |oxygen |and |breathing |are |priority |
nursing |interventions.
The |client |with |a |C6 |SCI |is |admitted |to |the |emergency |department |complaining |of |a |severe |
pounding |headache |and |has |a |BP |of |180/110. |Which |intervention |should |the |emergency |
department |nurse |implement?
A. |Keep |the |client |flat |in |bed.
B. |Dim |the |lights |in |the |room.
C. |Assess |for |bladder |distention.
D. |Administer |a |narcotic |analgesic.
C. |Assess |for |bladder |distention.
Rationale:
This |is |an |acute |emergency |caused |by |exaggerated |autonomic |responses |to |stimuli |and |only |
occurs |after |spinal |shock |has |resolved |in |the |client |with |a |spinal |cord |injury |above |T6. |The |
most |common |cause |is |a |full |bladder.
TEST |TAKING |HINT: |The |test |taker |should |apply |the |nursing |process |when |answering |
questions, |and |assessing |the |client |comes |first, |before |administering |any |type |of |medication.
,We |have |an |expert-written |solution |to |this |problem!
The |34-year-old |male |client |with |an |SCI |is |sharing |with |the |nurse |that |he |is |worried |about |
finding |employment |after |being |discharged |from |the |rehabilitation |unit. |Which |intervention |
should |the |nurse |implement?
A. |Refer |the |client |to |the |American |Spinal |Cord |Injury |Association |(ASIA).
B. |Refer |the |client |to |the |state |rehabilitation |commission.
C. |Ask |the |social |worker |(SW) |about |applying |for |disability.
D. |Suggest |that |the |client |talk |with |his |significant |other |about |this |concern.
B. |Refer |the |client |to |the |state |rehabilitation |commission.
Rationale:
The |rehabilitation |commission |of |each |state |will |help |evaluate |and |determine |if |the |client |can |
receive |training |or |education |for |another |occupation |after |injury.
TEST |TAKING |HINT: |If |the |question |mentions |a |specific |age |for |a |client, |the |nurse |should |
consider |it |when |attempting |to |answer |the |question. |This |is |a |young |person |who |needs |to |find
|gainful |employment. |Remember |Erickson's |stages |of |growth |and |development.
We |have |an |expert-written |solution |to |this |problem!
The |nurse |is |conducting |a |support |group |for |clients |diagnosed |with |Parkinson's |disease |and |
their |significant |others. |Which |information |regarding |psychosocial |needs |should |be |included |in
|the |discussion?
A. |The |client |should |discuss |feelings |about |being |placed |on |a |ventilator.
B. |The |client |may |have |rapid |mood |swings |and |become |easily |upset.
C. |Pill-rolling |tremors |will |become |worse |when |the |medication |is |wearing |off.
D. |The |client |may |automatically |start |to |repeat |what |another |person |says.
B. |The |client |may |have |rapid |mood |swings |and |become |easily |upset.
Rationale:
These |are |psychosocial |manifestations |ofPD. |These |should |be |discussed |in |the |support |
meeting.
, TEST |TAKING |HINT: |Psychosocial |problems |should |address |the |client's |feelings |or |interactions |
with |another |person.
We |have |an |expert-written |solution |to |this |problem!
The |nurse |is |caring |for |clients |on |a |medical-surgical |floor. |Which |clients |should |be |assessed |
first?
A. |The |65-year-old |client |diagnosed |with |seizures |who |is |complaining |of |a |headache |that |is |a
|"2" |on |a |1-to-10 |scale.
B. |The |24-year-old |client |diagnosed |with |a |T10 |spinal |cord |injury |who |cannot |move |his |toes.
C. |The |58-year-old |client |diagnosed |with |Parkinson's |disease |who |is |crying |and |worried |about |
her |facial |appearance.
D. |The |62-year-old |client |diagnosed |with |a |cerebrovascular |accident |who |has |a |resolving |left |
hemiparesis.
C. |The |58-year-old |client |diagnosed |with |Parkinson's |disease |who |is |crying |and |worried |about |
her |facial |appearance.
Rationale:
Body |image |is |a |concern |for |clients |diagnosed |with |PD. |This |client |is |the |one |client |who |is |not |
experiencing |expected |sequelae |of |the |disease.
TEST |TAKING |HINT:
At |times |a |psychological |problem |can |have |priority. |All |the |physical |problems |are |expected |and
|are |not |life |threatening |or |life |altering.
The |male |client |diagnosed |with |CKD |has |received |the |initial |dose |of |erythropoietin, |a |biologic |
response |modifier, |one |(1) |week |ago. |Which |complaint |by |the |client |indicates |the |need |to |
notify |the |health-care |provider?
A. |The |client |complains |of |flu-like |symptoms.
B. |The |client |complains |of |being |tired |all |the |time.
C. |The |client |reports |an |elevation |in |his |blood |pressure.
D. |The |client |reports |discomfort |in |his |legs |and |back.
C. |The |client |reports |an |elevation |in |his |blood |pressure.
