NRSG 2500 Test 6 (Units 11, 12, & 13) Questions With
Complete Solutions
(Spinal) Accessory Nerve XI Correct Answer -motor
-sternocleidomastoid and trapezius muscles
9 things not to say to someone with a brain injury Correct
Answer -you seem just fine to me-brain injury is often invisible
-maybe you're just not trying hard enough (you're lazy)-lazy is
not the same as apathy
-you're such a grump-irritability is one of the most common
signs of a brain injury
-how many times do i have to tell you-memory problems are
common and frustrating
-do you have any idea how much I do for you-they may not, and
guilt only adds to the frustration
-your problem is all the medications you take-they need the
medications they take, sluggishness could be a symptom of a
bigger problem
-let me do that for you-feeling the loss of independence and
control may already be affecting them
-try to think positively-rumination is usually related to
depression or anxiety, and treating those problems may help
break the negative thinking cycle
-you're lucky to be alive-a person with a brain injury is six times
more likely to have suicidal thoughts than someone without a
brain injury
Abducens Nerve VI Correct Answer -motor
-muscles that move the eye
,AD interventions Correct Answer -place pt in seated position
to lower bp
-rapid assessment to identify and eliminate cause
*empty the bladder-check catheter, irrigate, replace
*examine the rectum for fecal mass-remove mass
*examine skin-pressure, irritation, broken skin, loosen clothing,
shoes, toenails
*examine any other stimulus-objects next to skin, draft of cold
air
-hydralazine, nipride-lower bp
-label chart as "at risk for AD"
-educate pt in prevention and management
-baclofen for muscle spasms
Anterior Cord Syndrome Correct Answer -2/3 or anterior and
spinal artery
-paraplegia below the level of injury
-bilateral loss of pain and temp sensation with preservation of
proprioception and vibratory senses below the level of injury
-worst prognosis for recovery (10-20%); long periods of rehab
Assessing neurological function Correct Answer -cerebral
function-mental status, intellectual-cognition function, thought
content, emotion status, language ability, impact on lifestyle,
LOC, perception, motor, and speech
-cranial nerves-sensory, motor, or mixed nerves
-motor system-posture, gait, muscle tone and strength,
coordination and balance
-sensory system-tactile sensation, superficial pain, vibration and
position sense
-reflexes-gag, corneal plantar (Babinski), and deep tendon
, Assessment of altered mental status Correct Answer -LOC is
the most important indicator of the pts condition
-glasgow coma score (GCS) 3-15
-pupils-round and reactive
-motor-symmetry vs asymmetry
-sensation-numbness, tingling, painful stimuli
-speech-aphasia (receptive, expressive, global), slurred
-voluntary vs involuntary reflexes
Autonomic Dysreflexia (AD) Correct Answer -acute
emergency, life threatening-can cause seizures, stroke, even
death. Exaggerated autonomic responses to stimuli that are
harmless in normal people. Occurs in SCIs above T6
-causes-distended bladder (most common), distention or
contraction of visceral organs (constipation), impaction,
stimulation of the skin, tactile, pain, thermal stimuli, pressure
ulcer; sexual activity--over stimulation, menstrual cramps, labor
and delivery, men sitting on scrotum, skeletal fractures
-symptoms include severe pounding HA, sudden increase in bp
(200/100), profuse diaphoresis on forehead, blotching, flushed
red face, cold and clammy skin, goosebumps, restlessness,
nausea, nasal congestion, bradycardia <60bpm
Autonomic Nervous System Correct Answer -
sympathetic-"fight or flight" responses; main nt is norepi
-parasympathetic-"rest and digest"; controls mostly visceral
functions; main nt is acetylcholine (ACh)
AVPU Correct Answer -alert, responds to verbal stimuli,
responds to painful stimuli, unresponsive
Complete Solutions
(Spinal) Accessory Nerve XI Correct Answer -motor
-sternocleidomastoid and trapezius muscles
9 things not to say to someone with a brain injury Correct
Answer -you seem just fine to me-brain injury is often invisible
-maybe you're just not trying hard enough (you're lazy)-lazy is
not the same as apathy
-you're such a grump-irritability is one of the most common
signs of a brain injury
-how many times do i have to tell you-memory problems are
common and frustrating
-do you have any idea how much I do for you-they may not, and
guilt only adds to the frustration
-your problem is all the medications you take-they need the
medications they take, sluggishness could be a symptom of a
bigger problem
-let me do that for you-feeling the loss of independence and
control may already be affecting them
-try to think positively-rumination is usually related to
depression or anxiety, and treating those problems may help
break the negative thinking cycle
-you're lucky to be alive-a person with a brain injury is six times
more likely to have suicidal thoughts than someone without a
brain injury
Abducens Nerve VI Correct Answer -motor
-muscles that move the eye
,AD interventions Correct Answer -place pt in seated position
to lower bp
-rapid assessment to identify and eliminate cause
*empty the bladder-check catheter, irrigate, replace
*examine the rectum for fecal mass-remove mass
*examine skin-pressure, irritation, broken skin, loosen clothing,
shoes, toenails
*examine any other stimulus-objects next to skin, draft of cold
air
-hydralazine, nipride-lower bp
-label chart as "at risk for AD"
-educate pt in prevention and management
-baclofen for muscle spasms
Anterior Cord Syndrome Correct Answer -2/3 or anterior and
spinal artery
-paraplegia below the level of injury
-bilateral loss of pain and temp sensation with preservation of
proprioception and vibratory senses below the level of injury
-worst prognosis for recovery (10-20%); long periods of rehab
Assessing neurological function Correct Answer -cerebral
function-mental status, intellectual-cognition function, thought
content, emotion status, language ability, impact on lifestyle,
LOC, perception, motor, and speech
-cranial nerves-sensory, motor, or mixed nerves
-motor system-posture, gait, muscle tone and strength,
coordination and balance
-sensory system-tactile sensation, superficial pain, vibration and
position sense
-reflexes-gag, corneal plantar (Babinski), and deep tendon
, Assessment of altered mental status Correct Answer -LOC is
the most important indicator of the pts condition
-glasgow coma score (GCS) 3-15
-pupils-round and reactive
-motor-symmetry vs asymmetry
-sensation-numbness, tingling, painful stimuli
-speech-aphasia (receptive, expressive, global), slurred
-voluntary vs involuntary reflexes
Autonomic Dysreflexia (AD) Correct Answer -acute
emergency, life threatening-can cause seizures, stroke, even
death. Exaggerated autonomic responses to stimuli that are
harmless in normal people. Occurs in SCIs above T6
-causes-distended bladder (most common), distention or
contraction of visceral organs (constipation), impaction,
stimulation of the skin, tactile, pain, thermal stimuli, pressure
ulcer; sexual activity--over stimulation, menstrual cramps, labor
and delivery, men sitting on scrotum, skeletal fractures
-symptoms include severe pounding HA, sudden increase in bp
(200/100), profuse diaphoresis on forehead, blotching, flushed
red face, cold and clammy skin, goosebumps, restlessness,
nausea, nasal congestion, bradycardia <60bpm
Autonomic Nervous System Correct Answer -
sympathetic-"fight or flight" responses; main nt is norepi
-parasympathetic-"rest and digest"; controls mostly visceral
functions; main nt is acetylcholine (ACh)
AVPU Correct Answer -alert, responds to verbal stimuli,
responds to painful stimuli, unresponsive
