adult health 2 hesi
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."
Correct answers 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?
E. Decreased heart rate
F. Amnesia
G. Constipation
H.Dry mouth Correct answers 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?
I. Central cord syndrome
J. Spinal shock syndrome
K. Anterior cord syndrome
L.Brown-Séquard syndrome Correct answers 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 Correct answers 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?
E. Tachycardia
F. Hypotension
G. Hot, dry skin
H.Throbbing headache Correct answers 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?
I. Risk for impairment of tissue integrity caused by paralysis
J. Altered patterns of urinary elimination caused by quadriplegia
K. Altered family and individual coping caused by the extent of trauma
L.Ineffective airway clearance caused by high cervical spinal cord injury
Correct answers 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?
M.Pain assessment
N. Glasgow Coma Scale
O. Respiratory assessment
P.Musculoskeletal assessment Correct answers 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.
Which of the following signs and symptoms in a patient with a T4 spinal
cord injury should alert the nurse to the possibility of autonomic
dysreflexia?
Q. Headache and rising blood pressure
R. Irregular respirations and shortness of breath
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."
Correct answers 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?
E. Decreased heart rate
F. Amnesia
G. Constipation
H.Dry mouth Correct answers 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?
I. Central cord syndrome
J. Spinal shock syndrome
K. Anterior cord syndrome
L.Brown-Séquard syndrome Correct answers 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 Correct answers 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?
E. Tachycardia
F. Hypotension
G. Hot, dry skin
H.Throbbing headache Correct answers 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?
I. Risk for impairment of tissue integrity caused by paralysis
J. Altered patterns of urinary elimination caused by quadriplegia
K. Altered family and individual coping caused by the extent of trauma
L.Ineffective airway clearance caused by high cervical spinal cord injury
Correct answers 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?
M.Pain assessment
N. Glasgow Coma Scale
O. Respiratory assessment
P.Musculoskeletal assessment Correct answers 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.
Which of the following signs and symptoms in a patient with a T4 spinal
cord injury should alert the nurse to the possibility of autonomic
dysreflexia?
Q. Headache and rising blood pressure
R. Irregular respirations and shortness of breath
