COMPLEX EXAM 3 QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS GRADED A 2024

The nurse is performing an assessment of a client with a C3 spinal cord injury that occurred three days ago. Based on this information, what is the priority for this client? Blood Pressure 188/98 mmHg Heart Rate 56 bpm Flushed skin present Diaphoresis present A) Notify the health care provider of heart rate B) Lower the head of the bed C) Administer the prescribed IV fluids D) Administer prescribed antihypertensive D) Administer prescribed antihypertensive The nurse is caring for a client with a T-7 injury hospital day one and finds a loss of motor and sensory function of the lower extremities. The following day, the nurse finds sensory deficit has extended to the upper extremities. What is most likely cause for this change? A) Possible re-injury of unknown organ B) Lack of patient cooperation C) Inadequate previous assessment D) Secondary injury related to cord swelling D) Secondary injury related to cord swelling The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued Taking medications as scheduled Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress. A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition A temporary worsening of the condition Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements Impaired voluntary movements Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.