HESI adult health 2: Practice Questions & Answers: Updated

A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections." (Ans- c. SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE. Midazolam (Versed) has been ordered for a patient to be administered by injection 30 minutes prior to a colonoscopy. The nurse informs the patient that one of the most common side effects of this medication is which effect? A. Decreased heart rate B. Amnesia C. Constipation D. Dry mouth (Ans- b. Versed is known to cause amnesia and anxiolysis as well as sedation and is therefore commonly used prior to certain procedures. The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome (Ans- b. About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function. Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses (Ans- a. Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache (Ans- d. Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis. When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Risk for impairment of tissue integrity caused by paralysis B. Altered patterns of urinary elimination caused by quadriplegia C. Altered family and individual coping caused by the extent of trauma D. Ineffective airway clearance caused by high cervical spinal cord injury (Ans- d. Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs. The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment (Ans- c. Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status