ATI MEDSURG 2 &3 NUR265
ACCURATE ANSWERS FOR
NEURO-SHOCK & BURNS
PRACTICE ALL CORRECT
The nurse walks into the room and observes the client experiencing a tonic-
clonic seizure. Which intervention should the nurse implement first?
A - Restrain the client to protect from injury
B - Flex the neck to ensure stabilization
C - Use a tongue blade to open the airway
D - Turn the client on the side to aid ventilation
D - Turn the client on the side to aid ventilation
A 25 yo client is admitted with an injury resulting in a complete C7
transection of the spinal cord. Which action should the nurse anticipate the
need for in the immediate post-op period?
A - Bladder and bowel training
B - Diaphragmatic pacing
C - Monitoring for autonomic dysreflexia
D - Ventilatory support
D - Ventilatory support
,A nurse is assessing a client to see if he is comatose. Which of the following
GCS is indicative of a coma?
A - Nine
B - One
C - Six
D - Zero
C - Six
A female client with Guillain-Barré syndrome has paralysis affecting the
respiratory muscles and requires mechanical ventilation. When the client
asks the nurse about the paralysis, how should the nurse respond?
a. "You may have difficulty believing this, but the paralysis caused by this
disease is temporary."
b. "You'll have to accept the fact that you're permanently paralyzed.
However, you won't have any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."
a. "You may have difficulty believing this, but the paralysis caused by this
disease is temporary."
A female client has clear fluid leaking from the nose following a basilar skull
fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
,c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
d. Separates into concentric rings and test positive of glucose
The nurse is obtaining a health history for a client admitted to the hospital
with a tentative diagnosis of Guillain- Barre syndrome. Which health history
question will best elicit information that supports the diagnosis?
A - "Have you experienced an infection lately?"
B - "Is there a history of this disorder in your family?"
C - "Did you receive a head injury in the past year?"
D - "What medications have you taken in the last 3 months?"
A - "Have you experienced an infection lately?"
What are the early signs of cerebral hypoxia?
A - Irritability and restlessness
B - Nausea and unconsciousness
C - Eyes rolling back and fingernail clubbing
D - Headache and tachycardia
A - Irritability and restlessness
The nurse is assessing the client diagnosed with bacterial meningitis. Which
clinical manifestation would support the diagnosis of bacterial meningitis?
, A - Positive Babinski's sign and peripheral paresthesia
B - Negative Chvostek's sign and facial tingling
C - Positive Kernig's sign and nuchal rigidity
D - Negative Trousseau's sign and nystagmus
C - Positive Kernig's sign and nuchal rigidity
A patient with a fever is lethargic and has a blood pressure of 89/56. The
patient's white blood cell count is elevated. The physician suspects the
patient is developing septic shock. What other findings indicate this patient
is in the "early" or "compensated" stage of septic shock? Select all that
apply:
A. Urinary output of 60 mL over 4 hours
B. Warm and flushed skin
C. Tachycardia
D. Bradypnea
B. Warm and flushed skin
C. Tachycardia
Which patients are NOT a candidate for tissue plasminogen activator (tPA) for
the treatment of stroke? Select All That Apply
A. A patient with a CT scan that is negative.
B. A patient whose blood pressure is 200/110.
ACCURATE ANSWERS FOR
NEURO-SHOCK & BURNS
PRACTICE ALL CORRECT
The nurse walks into the room and observes the client experiencing a tonic-
clonic seizure. Which intervention should the nurse implement first?
A - Restrain the client to protect from injury
B - Flex the neck to ensure stabilization
C - Use a tongue blade to open the airway
D - Turn the client on the side to aid ventilation
D - Turn the client on the side to aid ventilation
A 25 yo client is admitted with an injury resulting in a complete C7
transection of the spinal cord. Which action should the nurse anticipate the
need for in the immediate post-op period?
A - Bladder and bowel training
B - Diaphragmatic pacing
C - Monitoring for autonomic dysreflexia
D - Ventilatory support
D - Ventilatory support
,A nurse is assessing a client to see if he is comatose. Which of the following
GCS is indicative of a coma?
A - Nine
B - One
C - Six
D - Zero
C - Six
A female client with Guillain-Barré syndrome has paralysis affecting the
respiratory muscles and requires mechanical ventilation. When the client
asks the nurse about the paralysis, how should the nurse respond?
a. "You may have difficulty believing this, but the paralysis caused by this
disease is temporary."
b. "You'll have to accept the fact that you're permanently paralyzed.
However, you won't have any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."
a. "You may have difficulty believing this, but the paralysis caused by this
disease is temporary."
A female client has clear fluid leaking from the nose following a basilar skull
fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
,c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
d. Separates into concentric rings and test positive of glucose
The nurse is obtaining a health history for a client admitted to the hospital
with a tentative diagnosis of Guillain- Barre syndrome. Which health history
question will best elicit information that supports the diagnosis?
A - "Have you experienced an infection lately?"
B - "Is there a history of this disorder in your family?"
C - "Did you receive a head injury in the past year?"
D - "What medications have you taken in the last 3 months?"
A - "Have you experienced an infection lately?"
What are the early signs of cerebral hypoxia?
A - Irritability and restlessness
B - Nausea and unconsciousness
C - Eyes rolling back and fingernail clubbing
D - Headache and tachycardia
A - Irritability and restlessness
The nurse is assessing the client diagnosed with bacterial meningitis. Which
clinical manifestation would support the diagnosis of bacterial meningitis?
, A - Positive Babinski's sign and peripheral paresthesia
B - Negative Chvostek's sign and facial tingling
C - Positive Kernig's sign and nuchal rigidity
D - Negative Trousseau's sign and nystagmus
C - Positive Kernig's sign and nuchal rigidity
A patient with a fever is lethargic and has a blood pressure of 89/56. The
patient's white blood cell count is elevated. The physician suspects the
patient is developing septic shock. What other findings indicate this patient
is in the "early" or "compensated" stage of septic shock? Select all that
apply:
A. Urinary output of 60 mL over 4 hours
B. Warm and flushed skin
C. Tachycardia
D. Bradypnea
B. Warm and flushed skin
C. Tachycardia
Which patients are NOT a candidate for tissue plasminogen activator (tPA) for
the treatment of stroke? Select All That Apply
A. A patient with a CT scan that is negative.
B. A patient whose blood pressure is 200/110.
