NUR 417 Med Surg Final Exam
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1. To prevent autonomic dysreflexia, which nursing ac- Assist to plan a prescribed
tion should the home health nurse include in the plan bowel program.
of care for a patient who
has paraplegia at the T4 level?
2. The nurse is admitting a patient who has a neck frac- Hypotension and warm
ture at the C6 level to the intensive care unit. Which extremities
finding on the nursing
assessment is congruent with neurogenic shock?
3. What should the nurse explain to the patient who has Function of both arms
a T2 spinal cord transection injury? should be maintained.
4. What should the nurse include in a rehabilitation plan Propel a manual wheel-
as an appropriate goal for a 30-yr-old patient with a chair on a flat surface.
C6 spinal cord injury?
5. A patient with paraplegia resulting from a T9 spinal Instruct the patient how to
cord injury has a neurogenic reflexic bladder. Which self-catheterize.
action should the nurse
include in the plan of care?
6. A 20-yr-old patient who sustained a T2 spinal cord Ask the patient to provide
injury 10 days ago tells the nurse, "I want to be trans- input for the plan of care.
ferred to a hospital where
the nurses know what they are doing." Which action
should the nurse appropriately take?
7. A 38-yr-old patient who has had a spinal cord injury Develop a plan to in-
returned home following a stay in a rehabilitation fa- crease the patient's inde-
cility. The home care pendence in consultation
nurse notes the spouse is performing many of the with the
activities that the patient had been managing unas- patient and the spouse.
, NUR 417 Med Surg Final Exam
Study online at https://quizlet.com/_jg1bg1
sisted during rehabilitation.
What should the nurse identify as the most appropri-
ate action at this phase of rehabilitation?
8. Which action should the nurse recognize has the high- Assessment of respiratory
est priority for a patient who was admitted 16 hours rate and effort
earlier with a C5 spinal
cord injury?
9. A patient who had a C7 spinal cord injury 1 week Push upward on the epi-
ago has a weak cough effort and crackles. What initial gastric area as the patient
intervention should the coughs.
nurse perform?
10. A patient with a history of T3 spinal cord injury is ad- Assess the blood pressure
mitted with dermal ulcers. The patient tells the nurse, (BP).
"I have a pounding
headache and I feel sick to my stomach." Which action
should the nurse take first?
11. A patient with a T4 spinal cord injury asks the nurse if Multiple options are avail-
he will be able to be sexually active. Which information able to maintain sexuality
should the nurse after spinal cord injury.
include in an initial response?
12. Which collaborative and nursing actions should the Urinary catheter care
nurse include in the plan of care for a patient who Continuous cardiac moni-
experienced a T2 spinal cord toring
transection 24 hours ago? (Select all that apply.) Administration of H2 re-
ceptor blockers
Maintenance of a warm
room temperature
, NUR 417 Med Surg Final Exam
Study online at https://quizlet.com/_jg1bg1
13. In which order should the nurse perform the follow- a. Infuse normal saline at
ing actions for a patient admitted to the emergency 150 mL/hr.
department with possible C5 b. Monitor cardiac rhythm
spinal cord trauma? (Put a comma and a space be- and blood pressure.
tween each answer choice [A, B, C, D, E].) c. Administer O2 using a
non-rebreather mask.
d. Immobilize the patient's
head, neck, and spine.
e. Transfer the patient to
radiology for spinal com-
puted tomography (CT).
ANS:
D, C, B, A, E
14. Family members of a patient who has a traumatic "The monitoring system
brain injury ask the nurse about the purpose of the helps show whether blood
ventriculostomy system being flow to the brain is ade-
used for intracranial pressure monitoring. Which re- quate."
sponse by the nurse is best for this situation?
15. Admission vital signs for a patient who has a brain Blood pressure 154/68
injury are blood pressure of 128/68 mm Hg, pulse of mm Hg, pulse 56
110 beats/min, and of beats/min, respirations 12
respirations 26 breaths/min. Which set of vital signs, breaths/min
if taken 1 hour later, will be of most concern to the
nurse?
16. When a brain-injured patient responds to nail bed Decorticate posturing
pressure with internal rotation, adduction, and flexion
of the arms, how should
the nurse report the response?
17. Intracranial pressure
Study online at https://quizlet.com/_jg1bg1
1. To prevent autonomic dysreflexia, which nursing ac- Assist to plan a prescribed
tion should the home health nurse include in the plan bowel program.
of care for a patient who
has paraplegia at the T4 level?
2. The nurse is admitting a patient who has a neck frac- Hypotension and warm
ture at the C6 level to the intensive care unit. Which extremities
finding on the nursing
assessment is congruent with neurogenic shock?
3. What should the nurse explain to the patient who has Function of both arms
a T2 spinal cord transection injury? should be maintained.
4. What should the nurse include in a rehabilitation plan Propel a manual wheel-
as an appropriate goal for a 30-yr-old patient with a chair on a flat surface.
C6 spinal cord injury?
5. A patient with paraplegia resulting from a T9 spinal Instruct the patient how to
cord injury has a neurogenic reflexic bladder. Which self-catheterize.
action should the nurse
include in the plan of care?
6. A 20-yr-old patient who sustained a T2 spinal cord Ask the patient to provide
injury 10 days ago tells the nurse, "I want to be trans- input for the plan of care.
ferred to a hospital where
the nurses know what they are doing." Which action
should the nurse appropriately take?
7. A 38-yr-old patient who has had a spinal cord injury Develop a plan to in-
returned home following a stay in a rehabilitation fa- crease the patient's inde-
cility. The home care pendence in consultation
nurse notes the spouse is performing many of the with the
activities that the patient had been managing unas- patient and the spouse.
, NUR 417 Med Surg Final Exam
Study online at https://quizlet.com/_jg1bg1
sisted during rehabilitation.
What should the nurse identify as the most appropri-
ate action at this phase of rehabilitation?
8. Which action should the nurse recognize has the high- Assessment of respiratory
est priority for a patient who was admitted 16 hours rate and effort
earlier with a C5 spinal
cord injury?
9. A patient who had a C7 spinal cord injury 1 week Push upward on the epi-
ago has a weak cough effort and crackles. What initial gastric area as the patient
intervention should the coughs.
nurse perform?
10. A patient with a history of T3 spinal cord injury is ad- Assess the blood pressure
mitted with dermal ulcers. The patient tells the nurse, (BP).
"I have a pounding
headache and I feel sick to my stomach." Which action
should the nurse take first?
11. A patient with a T4 spinal cord injury asks the nurse if Multiple options are avail-
he will be able to be sexually active. Which information able to maintain sexuality
should the nurse after spinal cord injury.
include in an initial response?
12. Which collaborative and nursing actions should the Urinary catheter care
nurse include in the plan of care for a patient who Continuous cardiac moni-
experienced a T2 spinal cord toring
transection 24 hours ago? (Select all that apply.) Administration of H2 re-
ceptor blockers
Maintenance of a warm
room temperature
, NUR 417 Med Surg Final Exam
Study online at https://quizlet.com/_jg1bg1
13. In which order should the nurse perform the follow- a. Infuse normal saline at
ing actions for a patient admitted to the emergency 150 mL/hr.
department with possible C5 b. Monitor cardiac rhythm
spinal cord trauma? (Put a comma and a space be- and blood pressure.
tween each answer choice [A, B, C, D, E].) c. Administer O2 using a
non-rebreather mask.
d. Immobilize the patient's
head, neck, and spine.
e. Transfer the patient to
radiology for spinal com-
puted tomography (CT).
ANS:
D, C, B, A, E
14. Family members of a patient who has a traumatic "The monitoring system
brain injury ask the nurse about the purpose of the helps show whether blood
ventriculostomy system being flow to the brain is ade-
used for intracranial pressure monitoring. Which re- quate."
sponse by the nurse is best for this situation?
15. Admission vital signs for a patient who has a brain Blood pressure 154/68
injury are blood pressure of 128/68 mm Hg, pulse of mm Hg, pulse 56
110 beats/min, and of beats/min, respirations 12
respirations 26 breaths/min. Which set of vital signs, breaths/min
if taken 1 hour later, will be of most concern to the
nurse?
16. When a brain-injured patient responds to nail bed Decorticate posturing
pressure with internal rotation, adduction, and flexion
of the arms, how should
the nurse report the response?
17. Intracranial pressure
