N434 Exam 2 Questions fully
solved & updated (graded
A+)
Which nursing action will the home health nurse include in the plan of care
for a patient with paraplegia at the T4 level in order to prevent autonomic
dysreflexia?
a. Support selection of a high-protein diet.
b. Discuss options for sexuality and fertility.
c. Assist in planning a prescribed bowel program.
d. Use quad coughing to strengthen cough efforts. - answer c. Assist in
planning a prescribed bowel program.
The nurse is admitting a patient with a neck fracture at the C6 level to the
intensive care unit. Which assessment finding(s) indicate(s) neurogenic
shock?
a. Hyperactive reflex activity below the level of injury
b. Involuntary, spastic movements of the arms and legs
c. Hypotension, bradycardia, and warm, pink extremities
d. Lack of sensation or movement below the level of injury - answer c.
Hypotension, bradycardia, and warm, pink extremities
,The nurse will explain to the patient who has a T2 spinal cord transection
injury that
a. use of the shoulders will be limited.
b. function of both arms should be retained.
c. total loss of respiratory function may occur.
d. tachycardia is common with this type of injury. - answer b. function of
both arms should be retained.
A patient with paraplegia resulting from a T9 spinal cord injury has a
neurogenic reflexic bladder. Which action will the nurse include in the plan
of care?
a. Teach the patient the Credé method.
b. Instruct the patient how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the patient to the toilet every 2 hours. - answer b. Instruct the
patient how to self-catheterize.
When the nurse is developing a rehabilitation plan for a 30-year-old
patient with a C6 spinal cord injury, an appropriate goal is that the patient
will be able to
a. drive a car with powered hand controls.
b. push a manual wheelchair on a flat surface.
, c. turn and reposition independently when in bed.
d. transfer independently to and from a wheelchair. - answer b. push a
manual wheelchair on a flat surface.
A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago
angrily tells the nurse "I want to be transferred to a hospital where the
nurses know what they are doing!" Which action by the nurse is best?
a. Clarify that abusive language will not be tolerated.
b. Request that the patient provide input for the plan of care.
c. Perform care without responding to the patient's comments.
d. Reassure the patient about the competence of the nursing staff. -
answer b. Request that the patient provide input for the plan of care.
A 38-year-old patient has returned home following rehabilitation for a
spinal cord injury. The home care nurse notes that the spouse is
performing many of the activities that the patient had been managing
unassisted during rehabilitation. The most appropriate action by the nurse
at this time is to
a. remind the patient about the importance of independence in daily
activities.
b. tell the spouse to stop because the patient is able to perform activities
independently.
c. develop a plan to increase the patient's independence in consultation
with the patient and the spouse.
solved & updated (graded
A+)
Which nursing action will the home health nurse include in the plan of care
for a patient with paraplegia at the T4 level in order to prevent autonomic
dysreflexia?
a. Support selection of a high-protein diet.
b. Discuss options for sexuality and fertility.
c. Assist in planning a prescribed bowel program.
d. Use quad coughing to strengthen cough efforts. - answer c. Assist in
planning a prescribed bowel program.
The nurse is admitting a patient with a neck fracture at the C6 level to the
intensive care unit. Which assessment finding(s) indicate(s) neurogenic
shock?
a. Hyperactive reflex activity below the level of injury
b. Involuntary, spastic movements of the arms and legs
c. Hypotension, bradycardia, and warm, pink extremities
d. Lack of sensation or movement below the level of injury - answer c.
Hypotension, bradycardia, and warm, pink extremities
,The nurse will explain to the patient who has a T2 spinal cord transection
injury that
a. use of the shoulders will be limited.
b. function of both arms should be retained.
c. total loss of respiratory function may occur.
d. tachycardia is common with this type of injury. - answer b. function of
both arms should be retained.
A patient with paraplegia resulting from a T9 spinal cord injury has a
neurogenic reflexic bladder. Which action will the nurse include in the plan
of care?
a. Teach the patient the Credé method.
b. Instruct the patient how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the patient to the toilet every 2 hours. - answer b. Instruct the
patient how to self-catheterize.
When the nurse is developing a rehabilitation plan for a 30-year-old
patient with a C6 spinal cord injury, an appropriate goal is that the patient
will be able to
a. drive a car with powered hand controls.
b. push a manual wheelchair on a flat surface.
, c. turn and reposition independently when in bed.
d. transfer independently to and from a wheelchair. - answer b. push a
manual wheelchair on a flat surface.
A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago
angrily tells the nurse "I want to be transferred to a hospital where the
nurses know what they are doing!" Which action by the nurse is best?
a. Clarify that abusive language will not be tolerated.
b. Request that the patient provide input for the plan of care.
c. Perform care without responding to the patient's comments.
d. Reassure the patient about the competence of the nursing staff. -
answer b. Request that the patient provide input for the plan of care.
A 38-year-old patient has returned home following rehabilitation for a
spinal cord injury. The home care nurse notes that the spouse is
performing many of the activities that the patient had been managing
unassisted during rehabilitation. The most appropriate action by the nurse
at this time is to
a. remind the patient about the importance of independence in daily
activities.
b. tell the spouse to stop because the patient is able to perform activities
independently.
c. develop a plan to increase the patient's independence in consultation
with the patient and the spouse.
