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NSG 4100 (AHIII) Exam 4 (ACTUAL /)
QUESTIONS AND VERIFIED ANSWERS .
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites, including the neck & upper back & knees.The pt also reports non-refreshing sleep, depression, & being anxious when dealing w multiple tasks. The nurse should
teach this pt about what treatments? Select all that apply:
- Minimal aerobic exercise
- Relaxation strategy (biofeedback)
- Anti-seizure during phenytoin
- Serotonin reuptake inhibitor (e.g. sertraline)
- Establish a regular sleep pattern
B, D, E
A pt w a head injury had been increasingly agitated & the nurse has consequently identifies a risk for injury. What is the nurses best intervention for preventing injury?
- restrain the pt as ordered
- administer opioids PRN as ordered
- arrange for friends & family members to sit w the pt
- pad the side rails of the pt's bed
D 1 / 4
A pt w a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the pt c/o sever throbbing HA. What should the nurse do first?
- check the pt's indwelling urinary catheter for kinks to
- lower the HOB to improve perfusion
- administer analgesia
- reassure the pt that headaches are expected after spinal cord
ensure patecny
injuries A
A pt is admitted to the neurologic ICU w a spinal cord injury.When assessing the pt the nurse notes there is a sudden depression fo reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
- epidural hemorrhage
- hypertensive emergency
- spinal shock
- hypovolemia
C
- / 4
An elderly woman found w a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is
the best rationale for the following physician orders: elevate
the HOB; keep the head in neutral alignment w no neck flexion or head rotation; avoid sharp hip flexion?
- to decrease cerebral arterial pressure
- to avoid impeding venous outflow
- to prevent flexion contractures
- to prevent aspiration of stomach contents
B
A pt w a T12 is in spinal shock. The nurse will expect to observe what assessment finding?
- absence of reflexes along w flaccid extremities
- positive Babinskis reflex along w spastic extremities
- hyperreflexia along w spastic extremities
- spasticity of all 4 extremities
A
A nurse is reviewing the trend of a pt's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the pt's status?
- reflex activity 3 / 4
- level of consciousness
- cognitive ability
- sensory involvement
B
The nurse is caring for a pt who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
- absence of pain response
- apnea
- coma
- absence of brain stem reflexes
- absence of deep tendon reflexes
B, C, D
Following a SCI a pt is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
- compete the pin site care to decrease risk of infection
- notify the neurosurgeon of the occurrence
- stabilize the head in a lateral position
- / 4
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