Question 1

A patient has the nursing diagnosis of Impaired Swallowing and complains of frequent heartburn. What is the most appropriate action by the nurse?

Accepted Answer

A

Question 2

A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication?

Accepted Answer

Oral Coumadin (warfarin) is a blood thinner that works by decreasing the blood's ability to clot, which can prevent stroke and other blood clotting disorders. However, certain foods and medications can affect the drug's efficacy and increase the risk of bleeding. Vitamin K-rich foods like spinach, kale, and broccoli can interfere with the effectiveness of Coumadin, so it's important for the patient to avoid or limit these foods while taking this medication. Additionally, patients on Coumadin should be aware of signs of excessive bleeding (such as bruising) and report any unusual symptoms to their healthcare provider. Monitoring blood pressure is important for patients with any cardiovascular disease, but it is not directly related to the effects of Coumadin. Low-fat diets may be beneficial for overall health, but there is no specific dietary restriction related to Coumadin and fat intake.

Question 3

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?

Accepted Answer

The halo fixation device allows for greater mobility, including the ability to get out of bed, compared to Gardner-Wells tongs, which are primarily used for cervical traction and limit mobility significantly.

Question 4

A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following?

Accepted Answer

Dexamethasone can cause hyperglycemia by increasing insulin resistance and decreasing glucose uptake in the peripheral tissues. Patients with a history of hypoglycemia are at increased risk of developing hyperglycemia when given dexamethasone. Therefore, the nurse should monitor the patient's blood glucose levels regularly and be prepared to intervene if hyperglycemia occurs.

Question 5

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse?

Accepted Answer

This is a common, temporary problem after a C7 cord injury.

Question 6

The healthcare provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured interverterbral disk. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe?

Accepted Answer

The answer of The healthcare provider orders 2.5 mg IV...

Question 7

Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy?

Accepted Answer

Using the log roll technique to turn the patient to the side is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy. This method ensures spinal alignment and minimizes the risk of injury while also reducing pressure on any one area of the skin, which can help prevent skin breakdown.

Question 8

Which of the following is the priority nursing diagnosis for the patient who has undergone surgery for a spinal fusion?

Accepted Answer

The answer of Which of the following is the priority...

Question 9

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?

Accepted Answer

A severe headache and an anxious feeling in a patient with a spinal cord injury at the T1 level could be symptoms of autonomic dysreflexia, a condition that can be triggered by a full bladder. Assessing for a full bladder is a critical initial step to address a potential cause of these symptoms.

Question 10

A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse?

Accepted Answer

Being alert for sudden weakness or numbness is the most important warning sign of stroke as it requires immediate medical attention. Other warning signs such as confusion or gradual onset of paralysis are also important but may not be as urgent as sudden weakness or numbness. Knowing family history and keeping a list of medications are important for overall health but not specifically related to stroke warning signs.

Question 11

A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After calling the ambulance, which is the most appropriate action by the nurse?

Accepted Answer

Immobilizing the neck and securing the head is the most appropriate action in this situation as the student may have sustained a spinal cord injury or a head injury. Moving the neck, even slightly, could potentially worsen the injury.

Question 12

A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following?

Accepted Answer

The patient's decreased level of consciousness, increased blood pressure, and slower reactive left pupil suggest an increased intracranial pressure, which can be a sign of a worsening stroke or other neurological condition.

Question 13

Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury?

Accepted Answer

Ineffective Airway Clearance is the priority nursing diagnosis for a patient with a spinal cord injury because of the possibility of respiratory compromise due to spinal cord swelling, injury, or anesthesia. It is essential to maintain patent airways and ensure adequate ventilation to prevent adverse events related to hypoxia or carbon dioxide retention. Fluid Volume Deficit, Impaired Physical Mobility, and Altered Tissue Perfusion may be priorities depending on the patient's specific condition but are not the priority nursing diagnosis in all cases.

Question 14

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient?  Select all that apply.

Accepted Answer

The nurse is responsible for assessing the patient's skin integrity to prevent pressure ulcers, administering pain medication to manage pain, and providing passive range of motion to maintain joint and muscle function. Modifying the traction weights and applying the traction are typically responsibilities of the physician or a trained technician under physician orders.

Question 15

A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive. Which nursing actions would be most appropriate for this patient?  Select all that apply.

Accepted Answer

The answer of A patient is placed in ventilator support...

Question 16

A nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Place the items in the correct order, starting with which action the nurse must first take. All options must be used.  Click and drag the options below to move them up or down.
A)Check victim's breathing 
B)Check victim's pulse 
C)Check victim's airway 
D)Immobilize the spine 
E)Check for victim responsiveness

Accepted Answer

The answer of A nurse witnesses a motor vehicle accident...

Question 17

A patient hospitalized with a known AV malformation begins to complain of a headache and becomes disorientated. Which is the most appropriate action by the nurse?

Accepted Answer

The symptoms of headache and disorientation in a patient with an AV malformation suggest a possible hemorrhage, which is a medical emergency. Preparing the patient for surgery is the most appropriate action as it may be necessary to address the bleeding.

Question 18

A nurse at a family gathering witnesses an adult relative drop her plate, become disoriented, and have noticeable changes in her speech. Organize the following nursing actions in order of priority, starting with the top priority.  Click and drag the options below to move them up or down.
A)Call 911.
B)Call ahead to the hospital.
C)Assist the patient to a safe position.
D)Comfort the patient's spouse.
E)Assess the patient's respiratory effort.

Accepted Answer

The answer of A nurse at a family gathering witnesses...

Question 19

The healthcare provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe?

Accepted Answer

The answer of The healthcare provider orders 15 mg IV...

Question 20

A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching?  Select all that apply.

Accepted Answer

The answer of A patient was diagnosed with a left...

Quiz 43: Nursing Care of Patients with Spinal Cord Disorders