Neuro-Shock & Burns practice test Latest Detailed Answer Key

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. 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.