ATI MERDISURG2 NUR265/DETAILED ANSWER
KEY FOR NEUROSHOCK -&BURNS PRACTICE -
NEW EDITION GUARANTEED PASS A+
GRADED!!
NEUROLOGICAL EMERGENCIES & SPINAL CORD INJURY
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
Answer: A, D, E Hypotension is correct because the loss of sympathetic tone causes vasodilation and a
drop in blood pressure; the priority is to maintain SBP ≥90 mmHg to perfuse the spinal cord. Absence of
bowel sounds is correct because spinal shock decreases peristalsis, leading to paralytic ileus. Weakened
gag reflex is correct and places the client at risk for aspiration, necessitating close monitoring. Polyuria is
incorrect; neurogenic bladder typically causes retention, not polyuria. Hyperthermia is incorrect; clients
are more prone to hypothermia due to an inability to regulate temperature (poikilothermia) .
2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for
phenytoin. Which statement by the client indicates a need for further teaching?
A) "I will notify my doctor before taking any other medications."
B) "I have made an appointment to see my dentist next week."
C) "I know that I cannot switch brands of this medication."
D) "I'll be glad when I can stop taking this medicine."
Answer: D Phenytoin is an anticonvulsant that clients commonly require for lifetime administration.
Stopping the medication abruptly can precipitate life-threatening seizures. Options A, B, and C indicate
correct understanding: many drug interactions occur with phenytoin, gingival hyperplasia is a side effect
requiring dental monitoring, and different brands have varying bioavailability .
3. A nurse enters a client's room and finds the client on the floor having a seizure. Which action should
the nurse take?
A) Insert a tongue blade in the client's mouth.
B) Place the client on his side.
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,C) Hold the client's arms and legs from moving.
D) Administer IV diazepam immediately.
Answer: B The priority is to protect the airway by placing the client on the side, which allows the tongue
to fall forward and secretions to drain. Inserting anything into the mouth can cause injury, and
restraining the client's movements can lead to fractures. Anticonvulsants like diazepam may be
prescribed, but immediate IV administration is not the first action for a seizure in progress unless it is
status epilepticus .
4. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA).
Which parameter should the nurse use first to assess the client's pain level?
A) Pulse and blood pressure
B) Behavioral indicators (facial grimacing, restlessness)
C) The client's ability to point to a pain scale
D) The client's verbal self-report
Answer: D Self-report is the gold standard for pain assessment. For a client with expressive aphasia, the
nurse should first attempt to get a self-report using alternative communication methods (e.g., pointing
to a pain scale, yes/no questions, holding up fingers). Assessing vital signs and behavioral indicators are
helpful but secondary to the client's own report .
5. A client who has had a lumbar puncture develops a severe headache that worsens when sitting up.
Which action should the nurse take first?
A) Administer an opioid analgesic as prescribed.
B) Encourage the client to lie flat and increase fluid intake.
C) Elevate the head of the bed to 30 degrees.
D) Notify the healthcare provider.
Answer: B A post-lumbar puncture headache is caused by cerebrospinal fluid (CSF) leakage from the
puncture site, leading to decreased CSF pressure. Lying flat and increasing fluids helps to alleviate the
headache. Elevating the HOB would worsen the headache. While opioid analgesics and provider
notification may occur, lying flat and increasing fluids is the immediate initial action .
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. What is the nurse's initial action?
A) Document the amount of drainage.
B) Obtain a culture of the drainage.
C) Check the drainage for glucose.
D) Notify the client's provider.
Answer: C Clear nasal drainage after a transsphenoidal hypophysectomy is a sign of a potential
cerebrospinal fluid (CSF) leak. The first action should be to assess the drainage for glucose, which would
indicate it is CSF. Documentation and provider notification are essential but follow the initial
assessment .
7. A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which
changes should the nurse include in the discussion? (Select all that apply.)
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,A) More difficulty seeing due to a greater sensitivity to glare
B) Decreased cough reflex
C) Decreased bladder capacity
D) Decreased systolic blood pressure
E) Dehydration of intervertebral discs
Answer: A, B, C, E Older adults experience increased sensitivity to glare (A), a decreased cough reflex
increasing infection risk (B), decreased bladder capacity (C), and dehydration of intervertebral discs (E).
Systolic blood pressure actually increases in older adults due to stiffening of blood vessels, making D
incorrect .
8. A client admitted for observation after experiencing an episode of chest pain has ECG changes
reflecting myocardial ischemia. Which laboratory value is most indicative of cardiac muscle damage?
A) Creatine kinase (CK)
B) Troponin
C) Myoglobin
D) Homocysteine
Answer: B Troponin is a protein that appears in the bloodstream when there is damage to the heart
muscle. It is the most specific and sensitive cardiac marker for myocardial infarction. While CK and
myoglobin may elevate, troponin is the gold standard .
SPINAL CORD INJURY & NEUROGENIC SHOCK
9. A patient with massive trauma and a possible spinal cord injury is admitted to the emergency
department (ED). Which finding by the caregiver will help confirm a diagnosis of neurogenic shock?
A) Cool, clammy skin
B) Inspiratory crackles
C) Apical heart rate of 48 beats/min
D) Temperature of 101.2°F
Answer: C Neurogenic shock is characterized by hypotension and bradycardia due to the loss of
sympathetic nervous system tone causing massive vasodilation. Unlike hypovolemic shock, the skin is
warm and dry. A bradycardic heart rate (48 bpm) is a key feature that differentiates it from other types
of shock .
10. A patient with a cervical neck fracture is admitted to the intensive care unit. Which findings would
the caregiver recognize as indicative of spinal shock?
A) Hyperreflexia and spasticity
B) Flaccid paralysis and loss of reflexes below the level of injury
C) Hypertension and tachycardia
D) Increased bowel and bladder tone
Answer: B Spinal shock occurs immediately after a spinal cord injury and is characterized by a temporary
loss of all reflex activity below the level of the injury. This manifests as flaccid paralysis and absent
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, reflexes. Hyperreflexia and spasticity are signs of resolution of spinal shock and the emergence of
autonomic dysreflexia. Neurogenic shock, a separate condition, causes hypotension and bradycardia .
11. A nurse is caring for a client with a suspected cervical cord injury. Which immediate intervention is
a priority to ensure adequate perfusion to the spinal cord?
A) Administer IV fluids to maintain blood pressure.
B) Place the client in Trendelenburg position.
C) Administer vasopressors to keep SBP >90 mmHg.
D) Initiate passive range of motion exercises.
Answer: C The goal in neurogenic shock is to maintain mean arterial pressure (MAP) and spinal cord
perfusion pressure (SCPP). While IV fluids are given, the priority is often to administer vasopressors (like
norepinephrine) to keep the SBP > 90 mmHg to prevent secondary spinal cord injury. Trendelenburg
position is not indicated .
12. A client is diagnosed with a spinal cord injury at the T6 level. The nurse should monitor the client
for which life-threatening complication?
A) Orthostatic hypotension
B) Autonomic dysreflexia
C) Paralytic ileus
D) Pressure ulcers
Answer: B Autonomic dysreflexia is a medical emergency that occurs in clients with spinal cord injury at
or above the T6 level. It is triggered by a noxious stimulus below the level of injury (e.g., distended
bladder, fecal impaction) and causes severe hypertension, bradycardia, and severe headache .
SHOCK STATES (SEPTIC, HYPOVOLEMIC, CARDIOGENIC)
13. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is
120 and the central venous and pulmonary artery wedge pressures are 4. Which of these orders by
the healthcare provider will the caregiver question?
A) Give furosemide (Lasix) 40 mg IV
B) Increase normal saline infusion to 150 mL/hr
C) Administer hydrocortisone (SoluCortef) 100 mg IV
D) Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
Answer: A In septic shock, the patient is fluid-resuscitative, requiring aggressive IV fluid administration.
Low CVP and PAWP (normal values 4-12 and 6-12, respectively) indicate hypovolemia. Administering a
loop diuretic like furosemide in a volume-depleted patient is contraindicated and would further
compromise renal perfusion. The other orders are appropriate for sepsis management .
14. After receiving 1000 mL of normal saline, the central venous pressure (CVP) for a patient who has
septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The caregiver will anticipate the
administration of which of the following?
A) Nitroglycerin (Tridil)
B) Sodium nitroprusside (Nipride)
4|Page SUCCESS!!!
KEY FOR NEUROSHOCK -&BURNS PRACTICE -
NEW EDITION GUARANTEED PASS A+
GRADED!!
NEUROLOGICAL EMERGENCIES & SPINAL CORD INJURY
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
Answer: A, D, E Hypotension is correct because the loss of sympathetic tone causes vasodilation and a
drop in blood pressure; the priority is to maintain SBP ≥90 mmHg to perfuse the spinal cord. Absence of
bowel sounds is correct because spinal shock decreases peristalsis, leading to paralytic ileus. Weakened
gag reflex is correct and places the client at risk for aspiration, necessitating close monitoring. Polyuria is
incorrect; neurogenic bladder typically causes retention, not polyuria. Hyperthermia is incorrect; clients
are more prone to hypothermia due to an inability to regulate temperature (poikilothermia) .
2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for
phenytoin. Which statement by the client indicates a need for further teaching?
A) "I will notify my doctor before taking any other medications."
B) "I have made an appointment to see my dentist next week."
C) "I know that I cannot switch brands of this medication."
D) "I'll be glad when I can stop taking this medicine."
Answer: D Phenytoin is an anticonvulsant that clients commonly require for lifetime administration.
Stopping the medication abruptly can precipitate life-threatening seizures. Options A, B, and C indicate
correct understanding: many drug interactions occur with phenytoin, gingival hyperplasia is a side effect
requiring dental monitoring, and different brands have varying bioavailability .
3. A nurse enters a client's room and finds the client on the floor having a seizure. Which action should
the nurse take?
A) Insert a tongue blade in the client's mouth.
B) Place the client on his side.
1|Page SUCCESS!!!
,C) Hold the client's arms and legs from moving.
D) Administer IV diazepam immediately.
Answer: B The priority is to protect the airway by placing the client on the side, which allows the tongue
to fall forward and secretions to drain. Inserting anything into the mouth can cause injury, and
restraining the client's movements can lead to fractures. Anticonvulsants like diazepam may be
prescribed, but immediate IV administration is not the first action for a seizure in progress unless it is
status epilepticus .
4. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA).
Which parameter should the nurse use first to assess the client's pain level?
A) Pulse and blood pressure
B) Behavioral indicators (facial grimacing, restlessness)
C) The client's ability to point to a pain scale
D) The client's verbal self-report
Answer: D Self-report is the gold standard for pain assessment. For a client with expressive aphasia, the
nurse should first attempt to get a self-report using alternative communication methods (e.g., pointing
to a pain scale, yes/no questions, holding up fingers). Assessing vital signs and behavioral indicators are
helpful but secondary to the client's own report .
5. A client who has had a lumbar puncture develops a severe headache that worsens when sitting up.
Which action should the nurse take first?
A) Administer an opioid analgesic as prescribed.
B) Encourage the client to lie flat and increase fluid intake.
C) Elevate the head of the bed to 30 degrees.
D) Notify the healthcare provider.
Answer: B A post-lumbar puncture headache is caused by cerebrospinal fluid (CSF) leakage from the
puncture site, leading to decreased CSF pressure. Lying flat and increasing fluids helps to alleviate the
headache. Elevating the HOB would worsen the headache. While opioid analgesics and provider
notification may occur, lying flat and increasing fluids is the immediate initial action .
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. What is the nurse's initial action?
A) Document the amount of drainage.
B) Obtain a culture of the drainage.
C) Check the drainage for glucose.
D) Notify the client's provider.
Answer: C Clear nasal drainage after a transsphenoidal hypophysectomy is a sign of a potential
cerebrospinal fluid (CSF) leak. The first action should be to assess the drainage for glucose, which would
indicate it is CSF. Documentation and provider notification are essential but follow the initial
assessment .
7. A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which
changes should the nurse include in the discussion? (Select all that apply.)
2|Page SUCCESS!!!
,A) More difficulty seeing due to a greater sensitivity to glare
B) Decreased cough reflex
C) Decreased bladder capacity
D) Decreased systolic blood pressure
E) Dehydration of intervertebral discs
Answer: A, B, C, E Older adults experience increased sensitivity to glare (A), a decreased cough reflex
increasing infection risk (B), decreased bladder capacity (C), and dehydration of intervertebral discs (E).
Systolic blood pressure actually increases in older adults due to stiffening of blood vessels, making D
incorrect .
8. A client admitted for observation after experiencing an episode of chest pain has ECG changes
reflecting myocardial ischemia. Which laboratory value is most indicative of cardiac muscle damage?
A) Creatine kinase (CK)
B) Troponin
C) Myoglobin
D) Homocysteine
Answer: B Troponin is a protein that appears in the bloodstream when there is damage to the heart
muscle. It is the most specific and sensitive cardiac marker for myocardial infarction. While CK and
myoglobin may elevate, troponin is the gold standard .
SPINAL CORD INJURY & NEUROGENIC SHOCK
9. A patient with massive trauma and a possible spinal cord injury is admitted to the emergency
department (ED). Which finding by the caregiver will help confirm a diagnosis of neurogenic shock?
A) Cool, clammy skin
B) Inspiratory crackles
C) Apical heart rate of 48 beats/min
D) Temperature of 101.2°F
Answer: C Neurogenic shock is characterized by hypotension and bradycardia due to the loss of
sympathetic nervous system tone causing massive vasodilation. Unlike hypovolemic shock, the skin is
warm and dry. A bradycardic heart rate (48 bpm) is a key feature that differentiates it from other types
of shock .
10. A patient with a cervical neck fracture is admitted to the intensive care unit. Which findings would
the caregiver recognize as indicative of spinal shock?
A) Hyperreflexia and spasticity
B) Flaccid paralysis and loss of reflexes below the level of injury
C) Hypertension and tachycardia
D) Increased bowel and bladder tone
Answer: B Spinal shock occurs immediately after a spinal cord injury and is characterized by a temporary
loss of all reflex activity below the level of the injury. This manifests as flaccid paralysis and absent
3|Page SUCCESS!!!
, reflexes. Hyperreflexia and spasticity are signs of resolution of spinal shock and the emergence of
autonomic dysreflexia. Neurogenic shock, a separate condition, causes hypotension and bradycardia .
11. A nurse is caring for a client with a suspected cervical cord injury. Which immediate intervention is
a priority to ensure adequate perfusion to the spinal cord?
A) Administer IV fluids to maintain blood pressure.
B) Place the client in Trendelenburg position.
C) Administer vasopressors to keep SBP >90 mmHg.
D) Initiate passive range of motion exercises.
Answer: C The goal in neurogenic shock is to maintain mean arterial pressure (MAP) and spinal cord
perfusion pressure (SCPP). While IV fluids are given, the priority is often to administer vasopressors (like
norepinephrine) to keep the SBP > 90 mmHg to prevent secondary spinal cord injury. Trendelenburg
position is not indicated .
12. A client is diagnosed with a spinal cord injury at the T6 level. The nurse should monitor the client
for which life-threatening complication?
A) Orthostatic hypotension
B) Autonomic dysreflexia
C) Paralytic ileus
D) Pressure ulcers
Answer: B Autonomic dysreflexia is a medical emergency that occurs in clients with spinal cord injury at
or above the T6 level. It is triggered by a noxious stimulus below the level of injury (e.g., distended
bladder, fecal impaction) and causes severe hypertension, bradycardia, and severe headache .
SHOCK STATES (SEPTIC, HYPOVOLEMIC, CARDIOGENIC)
13. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is
120 and the central venous and pulmonary artery wedge pressures are 4. Which of these orders by
the healthcare provider will the caregiver question?
A) Give furosemide (Lasix) 40 mg IV
B) Increase normal saline infusion to 150 mL/hr
C) Administer hydrocortisone (SoluCortef) 100 mg IV
D) Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
Answer: A In septic shock, the patient is fluid-resuscitative, requiring aggressive IV fluid administration.
Low CVP and PAWP (normal values 4-12 and 6-12, respectively) indicate hypovolemia. Administering a
loop diuretic like furosemide in a volume-depleted patient is contraindicated and would further
compromise renal perfusion. The other orders are appropriate for sepsis management .
14. After receiving 1000 mL of normal saline, the central venous pressure (CVP) for a patient who has
septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The caregiver will anticipate the
administration of which of the following?
A) Nitroglycerin (Tridil)
B) Sodium nitroprusside (Nipride)
4|Page SUCCESS!!!
