A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's
... [Show More] following statements demonstrates the need for further teaching about the disease?
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
D. "I understand that I'm going to be vulnerable to getting infections."
c. SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
Midazolam (Versed) has been ordered for a patient to be administered by injection 30 minutes prior to a colonoscopy. The nurse informs the patient that one of the most common side effects of this medication is which effect?
A. Decreased heart rate
B. Amnesia
C. Constipation
D. Dry mouth
b. Versed is known to cause amnesia and anxiolysis as well as sedation and is therefore commonly used prior to certain procedures.
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome
b. About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses
a. Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache
d. Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical spinal cord injury
d. Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize?
A. Pain assessment
B. Glasgow Coma Scale
C. Respiratory assessment
D. Musculoskeletal assessment
c. Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.
Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia?
A. Headache and rising blood pressure
B. Irregular respirations and shortness of breath
C. Decreased level of consciousness or hallucinations
D. Abdominal distention and absence of bowel sounds
a. Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.
Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia?
A. Urinary catheterization
B. Administration of benzodiazepines
C. Suctioning of the patient's upper airway
D. Placement of the patient in the Trendelenburg position
a. Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.
Which of the following characteristics of a patient's recent seizure is congruent with a partial seizure?
A. The patient lost consciousness during the seizure.
B. The seizure involved lip smacking and repetitive movements.
C. The patient fell to the ground and became stiff for 20 seconds.
D. The etiology of the seizure involved both sides of the patient's brain.
b. The most common complex partial seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.
Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)?
A. Vigilant infection control and adherence to standard precautions
B. Careful monitoring of neurologic vital signs and frequent reorientation
C. Maintenance of a calorie count and hourly assessment of intake and output
D. Assessment of blood pressure and monitoring for signs of orthostatic hypotension
a. Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in hypotension or fluid volume excess or deficit.
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient?
A. Provide multivitamins with each meal.
B. Provide a diet that is low in complex carbohydrates and high in protein.
C. Provide small, frequent meals throughout the day that are easy to chew and swallow.
D. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
c. Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated.
Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)?
A. Acute confusion
B. Bowel incontinence
C. Activity intolerance
D. Disturbed sleep pattern
c. The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.
The nurse who has administered a dose of risperidone (Risperdal) to a patient with delirium assesses for which of the following intended effects of the medication?
A. Lying quietly in bed
B. Alleviation of depression
C. Reduction in blood pressure
D. Disappearance of confusion
a. Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution.
When providing community health care teaching regarding the early warning signs of Alzheimer?s disease, which of the following signs would the nurse advise family members to report (select all that apply)?
A. Misplacing car keys
B. Losing sense of time
C. Difficulty performing familiar tasks
D. Problems with performing basic calculations
E. Becoming lost in a usually familiar environment
b, c, d, e. [Show Less]