NEURO FINAL EXAM

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					19. A client is admitted with a cervical spine injury sustained during a diving accident. When
planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

   A.   Impaired physical mobility
   B.   Ineffective breathing pattern
   C.   Disturbed sensory perception (tactile)
   D.   Dressing or grooming self-care deficit

 Correct Answer: B
 RATIONALES: Because a cervical spine injury can cause respiratory distress, the nurse should
take immediate action to maintain a patent airway and provide adequate oxygenation. The other
options may be appropriate for a client with a spinal cord injury — particularly during the course
of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.


The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The
nurse should respond that it:

   A.   dilates cerebral blood vessels.
   B.   constricts cerebral blood vessels.
   C.   decreases peripheral vascular resistance.
   D.   decreases the stimulation of baroreceptors.

 Correct Answer: B
 RATIONALES: Ergotamine relieves migraine headaches by constricting cerebral arterial
vessels. The drug's ability to prevent norepinephrine reuptake may add to this effect. The net
result is decreased pulsatile blood flow through the cerebral vessels and symptom relief.
Ergotamine doesn't decrease either peripheral vascular resistance or stimulation of baroreceptors.


The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing
intervention should the nurse implement?

   A.   Give the medication on an empty stomach.
   B.   Warn the client that he'll experience mouth dryness.
   C.   Schedule the medication before meals.
   D.   Administer the medication for complaints of muscle weakness or difficulty swallowing.

Correct Answer: C
RATIONALES: Because neostigmine's onset of action is 45 to 75 minutes, it
should be administered at least 45 minutes before eating to improve chewing and
swallowing. Taking neostigmine with a small amount of food reduces GI
adverse effects. Adverse effects of the medication include increased salivation,
bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be
given at scheduled times to ensure consistent blood levels.
A client is color blind. The nurse understands that this client has a problem
with:

    A.   rods.
    B.   cones.
    C.   lens.
    D.   aqueous humor.

 Correct Answer: B
 RATIONALES: Cones provide daylight color vision, and their stimulation is interpreted as
 color. If one or more types of cones are absent or defective, color blindness occurs. Rods are
 sensitive to low levels of illumination but can't discriminate color. The lens is responsible for
 focusing images. Aqueous humor is a clear watery fluid that isn't involved with color
 perception.


20. A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse
if he'll ever be able to walk again. Which response by the nurse is appropriate?

    A.   "If you keep a positive attitude, you can do anything."
    B.   "What makes you think you won't be able to walk again?"
    C.   "What has your physician told you about your ability to walk again?"
    D.   "Most likely you won't be able to, but we never know for sure."

 Correct Answer: C
 RATIONALES: The nurse should respond by asking the client what he's already been told
 about his ability to walk again. After assessing the client's knowledge, she can better respond
 to the client's questioning. Option 1 provides the client with false hope, and option 2 may place
 the client on the defensive. Option 4 is an inappropriate response.


A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow
sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based
on these findings, which action should the nurse take?
        A.   Change the client's indwelling urinary catheter.
        B.   Notify a physician of the findings.
        C.   Encourage coughing and deep-breathing exercises.
        D.   Contact central supply to request a respiratory isolation cart.



Correct Answer: B

RATIONALES: The nurse should notify the physician of these findings because they're signs of
pneumonia and a urinary tract infection. The physician will most likely order sputum and urine
specimens for culture and sensitivity testing. After the specimens are obtained, the physician will most
likely prescribe antibiotic therapy. Coughing and deep-breathing exercises can also be implemented to
mobilize secretions, but a client who sustains a severe stroke may not be able to perform these
exercises. Nothing suggests that the client requires respiratory isolation at this time. The physician
may provide an order to discontinue or change the indwelling urinary catheter.


A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle
relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice
daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:




1. long-term treatment of epilepsy.

2. postoperative pain management of laminectomy clients.

3. postoperative pain management of diskectomy clients.

4. treatment of spasticity associated with spinal cord lesions.



 Correct Answer: d

 RATIONALES: In addition to relieving painful muscle spasms, diazepam also is recommended for
 treatment of spasticity associated with spinal cord lesions. Diazepam's use is limited by its central
 nervous system effects and the tolerance that develops with prolonged use. The parenteral form of
 diazepam can treat status epilepticus, but the drug's sedating properties make it an unsuitable choice
 for long-term management of epilepsy. Diazepam isn't an analgesic agent.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:




    A.   allow time for the client to respond.
    B.   speak loudly and articulate clearly.
    C.   give the client a writing pad.
    D.   use short, simple sentences.



 Correct Answer: D

 RATIONALES: Although receptive aphasia allows the client to hear words, it impairs the ability to
 comprehend their meaning. The nurse should use short, simple sentences to promote
 comprehension. Allowing time for the client to respond might be helpful, but it's less important than
 simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't
 necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.




The nurse is working on a surgical floor. The nurse must logroll a client following a:




    A.   laminectomy.
    B.   thoracotomy.
    C.   hemorrhoidectomy.
    D.   cystectomy.




 Correct Answer: A

 RATIONALES: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep
 the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may
 turn himself or may be assisted into a comfortable position. Under normal circumstances,
 hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities
 immediately after surgery.
A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the
chart, the nurse notes that the client's extremity muscle strength is rated 1/5. What does this
mean?

   A.   Normal, full muscle strength is present.
   B.   Muscles move actively against gravity alone.
   C.   Muscle contraction is palpable and visible.
   D.   Muscle contraction or movement is undetectable.

 Correct Answer: C
        RATIONALES: Muscle strength is assessed and rated on a five-point scale in all four
extremities, comparing one side to the other. A rating of 1/5 indicates palpable, visible muscle
contraction on the affected side and normal, full muscle strength on the unaffected side. Normal,
full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on
the affected side with normal, full muscle strength on the unaffected side is rated 3/5.
Undetectable muscle contraction or movement on the affected side with normal, full muscle
strength on the unaffected side is rated 0/5



 A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative
 diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor,
 sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this
 client?



   A.   Lung auscultation and measurement of vital capacity and tidal volume
   B.   Evaluation for signs and symptoms of increased intracranial pressure (ICP)
   C.   Evaluation of pain and discomfort
   D.   Evaluation of nutritional status and metabolic state



 Correct Answer: A

 RATIONALES: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which
may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of
vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing
respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder,
polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and
discomfort and must assess the nutritional status, these assessments aren't priorities.
A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most
significant?

   A.    Warm, dry skin
   B.    Urine output of 40 ml/hour
   C.    Soft, nondistended abdomen
   D.    Even, unlabored respirations

Correct Answer: D
RATIONALES: A characteristic feature of Guillain-Barré syndrome is ascending weakness,
which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory
muscle weakness is a particularly dangerous effect of this disease progression because it may
lead to respiratory failure and death. Therefore, although all of the options are pertinent
assessment data, those related to respiratory function and status are most significant.


 A client is scheduled for an EEG after having a seizure for the first time. Client preparation
 for this test should include which instruction?

    A.   "Don't eat anything for 12 hours before the test."
    B.   "Don't shampoo your hair for 24 hours before the test."
    C.   "Avoid stimulants and alcohol for 24 to 48 hours before the test."
    D.   "Avoid thinking about personal matters for 12 hours before the test."

 Correct Answer: C
 RATIONALES: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea,
 alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the
 same reason, the client also should avoid antidepressants, tranquilizers, and anticonvulsants.)
 To avoid a reduced serum glucose level, which may alter test results, the client should eat
 normal meals before the test. The hair should be washed before an EEG because the
 electrodes must be applied to a clean scalp. The client's thoughts don't interfere with the test
 or its results.




A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair.
How should the nurse intervene first?

   A.    Initiate the code team response.
   B.    Put a padded tongue blade into the client's mouth and restrain her extremities.
   C.    Record the type of seizure and the time that it occurred.
   D.    Assist the client to a side-lying position on the floor, and protect her with linens.
Correct Answer: D
RATIONALES: The nurse should protect the client from injury by assisting her to a side-lying
position on the floor and padding the floor with bed linens. There is no need to initiate a
response from the code team because seizures are self-limiting. As long as the client's airway is
protected, her cardiopulmonary status isn't affected. The nurse shouldn't force anything into a
client's mouth during a seizure; doing so may cause injury. Documenting seizure activity is
important, but it doesn't take priority over client safety.




21. The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes.
Which comments by the client indicate that he understands the instructions?

    A. "I'll eat food that is very
       hot."

    B. "I'll try to chew my food on the unaffected
       side."

    C. "I can wash my face with cold
       water."

    D. "Drinking fluids at room temperature should reduce
       pain."

    E. "If brushing my teeth is too painful, I'll try to rinse my mouth
       instead."

 Correct Answer: b,d,e
 RATIONALES: The facial pain of trigeminal neuralgia is triggered by mechanical or thermal
 stimuli. Chewing food on the unaffected side and rinsing the mouth rather than brushing teeth
 reduce mechanical stimulation. Drinking fluids at room temperature reduces thermal
 stimulation. Eating hot food and washing the face with cold water are likely to trigger pain.




  22. A client comes to the emergency department complaining of headache, malaise, chills, fever,
  and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and
  respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion,
  a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign
 indicate?




1. Increased intracranial pressure (ICP)

2. Cerebral edema

3. Low cerebrospinal fluid (CSF) pressure

4. Meningeal irritation



 Correct Answer: D

 RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of
 meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate
 increased ICP, cerebral edema, or low CSF pressure.




   Shortly after admission to an acute care facility, a client with a seizure disorder develops
   status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon
   can the nurse administer a second dose of diazepam, if needed and prescribed?

     A. In 30 to 45 seconds

     B. In 10 to 15 minutes

     C. In 30 to 45 minutes
     D. In 1 to 2 hours

   Correct Answer: B
   RATIONALES: When used to treat status epilepticus, diazepam may be given every 10
   to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the
   regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24
   hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore,
   the dose can't be repeated in 30 to 45 seconds because the first dose wouldn't have been
   administered completely by that time. Waiting longer than 15 minutes to repeat the dose
   would increase the client's risk of complications associated with status epilepticus.
he nurse is caring for a client in a coma who has suffered a closed head injury. What
intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?




  A. Suction his airway every hour and as needed.

  B. Elevate the head of the bed to 30 degrees.

  C. Turn the client and change his position every 2 hours.

  D. Maintain a well-lit room.



Correct Answer: B

RATIONALES: To facilitate venous drainage and avoid jugular compression, the nurse
should elevate the head of the bed to 30 degrees. Suctioning increases ICP and shouldn't
be done on a regular basis. Turning from side to side increases the risk of jugular
compression and rise in ICP, so turning and changing positions should be avoided. The
room should be kept quiet and dimly lit.




 A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following
 symptoms: difficulty with recent and remote memory, irritability, depression,
 restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage
 of Alzheimer's disease?




   A. I

   B. II

   C. III

   D. IV



 Correct Answer: B
RATIONALES: Stage II is exhibited by the above listed symptoms as well as
communication difficulties, motor disturbances, forgetfulness, and psychosis. This
stage lasts 2 to 10 years. Stage I, which lasts 1 to 3 years, is characterized by memory
loss, poor judgment and problem-solving, difficulty adapting to new environments
and challenges, and agitation or apathy. Stage III is characterized by loss of all mental
abilities and the ability to care for self. There is no stage IV.

 The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should
 the nurse consider abnormal?




    A. More back pain than the first postoperative day

    B. Paresthesia in the dermatomes near the wounds

    C. Urine retention or incontinence

    D. Temperature of 99.2° F (37.3° C)



 Correct Answer: C

 RATIONALES: Urine retention or incontinence may indicate cauda equina
 syndrome, which requires immediate surgery. An increase in pain on the second
 postoperative day is common because the long-acting local anesthetic, which may
 have been injected during surgery, will wear off. Whereas paresthesia is common
 after surgery, progressive weakness or paralysis may indicate spinal nerve
 compression. A mild fever is also common after surgery but is considered
 significant only if it reaches 101° F (38.3° C).




   Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?




      A. Administering chloral hydrate (Noctec)

      B. Assessing laboratory test results as ordered
    C. Placing the client in Trendelenburg's position

    D. Monitoring the patency of an indwelling urinary catheter



Correct Answer: D




The nurse observes that a comatose client's response to painful stimuli is
decerebrate posturing. The client exhibits extended and pronated arms, flexed
wrists with palms facing backward, and rigid legs extended with plantar flexion.
Decerebrate posturing as a response to pain indicates:



    A. dysfunction in the cerebrum.

    B. risk for increased intracranial pressure.

    C. dysfunction in the brain stem.

    D. dysfunction in the spinal column.




Correct Answer: C




RATIONALES: Decerebrate posturing indicates damage of the upper brain stem.
Decorticate posturing indicates cerebral dysfunction. Increased intracranial
pressure is a cause of decortication and decerebration. Alterations in sensation or
paralysis indicate dysfunction in the spinal column
24. After a motor vehicle accident, a client is admitted to the medical-surgical unit with a
cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know
whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should
restrict this client to which position?

  A.   Flat
  B.   Supine, with the head of the bed elevated 30 degrees
  C.   Flat, except for logrolling as needed
  D.   A head elevation of 90 degrees to prevent cerebral swelling

Correct Answer: C
RATIONALES: When caring for a client with a possible cervical spinal
injury who's wearing a cervical collar, the nurse must keep the client flat
to decrease mobilization and prevent further injury to the spinal column.
The client can be logrolled, if necessary, with the cervical collar on.




A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing
intervention would reduce the client's risk of increased intracranial pressure (ICP)?




  A. Encouraging oral fluid intake

  B. Suctioning the client once each shift

  C. Elevating the head of the bed 90 degrees

  D. Administering a stool softener as prescribed



Correct Answer: D
RATIONALES: To prevent the client from straining at stool, which
may cause a Valsalva maneuver that increases ICP, the nurse
should institute a regular bowel program that includes use of a
stool softener. For a client at risk for increased ICP, the nurse
should prevent, not encourage, oral fluid intake and should
elevate the head of the bed only 30 degrees. Suctioning,
indicated for a client with lung congestion, isn't necessary for this
client.




 While bathing a client who sustained a stroke, a nurse is asked by a coworker to assist with repositioning
 another client. What should the nurse do?




    A. Ensure the client's privacy, put up the side rail, and
        explain that she'll return shortly.

    B. Explain that she must leave and ask the client to continue
        bathing.

    C. Leave the client and return as soon as possible.

    D. Explain to her coworker that she can't leave the client
        until she's finished bathing him.



 Correct Answer: A

 RATIONALES: The best approach is to explain to the client that
 she needs to leave, put up the side rail, and ensure the
 client's privacy. The client can't continue bathing
 independently; suggesting that he do so might frustrate him.
 The nurse shouldn't leave the client without an explanation,
 and she shouldn't refuse to help her coworker.
When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of
increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?




  A. Rising blood pressure and bradycardia

  B. Hypotension and bradycardia

  C. Hypotension and tachycardia

  D. Hypertension and narrowing pulse pressure



Correct Answer: A

RATIONALES: Late cardiovascular indicators of increased
ICP include rising blood pressure, bradycardia, and
widening pulse pressure — known collectively as Cushing's
triad. Increased ICP usually causes a bounding pulse; as
death approaches, the pulse becomes irregular and
thready.




 The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing
 interventions should be included in the client's care plan?

 Select all that apply:
       1. Make frequent changes in the client's routine.


       2. Engage the client in complex discussions to help improve his memory.


       3. Furnish the client's environment with familiar possessions.


       4. Assist the client with activities of daily living (ADLs) as necessary.


       5. Assign tasks in simple steps.
Correct Answer:
C,D,E
RATIONALES: A client with Alzheimer's disease
experiences progressive deterioration in cognitive
functioning. Familiar possessions may help to
orient the client. The client should be encouraged
to perform ADLs as much as possible but may
need assistance with certain activities. Using a
step-by-step approach helps the client complete
tasks independently. A client with Alzheimer's
disease functions best with consistent routines.
Complex discussions don't improve the memory of
a client with Alzheimer's disease.


 A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing
 response is to:




   A. hold the client's arm still to keep him from
       hitting anything.

   B. carefully move him to a flat surface and turn
       him on his side.

   C. allow him to remain in the chair but move all
       objects out of his way.

   D. place an oral airway in his mouth to maintain
       an open airway.



 Correct Answer: B

 RATIONALES: When caring for a client experiencing
 a tonic-clonic seizure, the nurse should take steps
 to ensure that the client can breathe and to protect
 the client from injury. In this situation, the nurse
   should help the client to a flat nonelevated surface
   and then position him on his side. These steps help
   reduce the risk of injury from falling or hitting
   surrounding objects. They also help establish an
   open airway. The client shouldn't be restrained
   during the seizure. Also, nothing should be placed
   in his mouth; anything in the mouth could impair
   ventilation and damage the inside of his mouth.




     Family members would like to bring in a birthday cake for a client with nerve damage. What
     cranial nerve needs to be functioning so the client can chew?

         A. Cranial nerve II

         B. Cranial nerve V
         C. Cranial nerve IX
         D. Cranial nerve X

     Correct Answer: B
     RATIONALES: Chewing is a function of
     cranial nerve V. Swallowing is a motor
     function of cranial nerves IX and X. Cranial
     nerve II doesn't have a motor function.




27. The nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is
appropriate?




  A. Establishing an intermittent catheterization routine
      every 4 hours
       B. Managing spasticity with range-of-motion exercises
            and medications

       C. Establishing an ambulation program using short leg
            braces

       D. Preventing autonomic dysreflexia by preventing
            bowel impactions



   Correct Answer: A

   RATIONALES: The paraplegic client with an L1-L2 injury will
   demonstrate flaccid paralysis. Developing an intermittent
   catheterization routine offers a way of manually draining
   the bladder, eliminating the need for an indwelling urinary
   catheter. Spasticity and autonomic dysreflexia are seen in
   clients with upper motor injuries above T6. With an injury
   at L1-L2, ambulation may be possible with long leg braces
   but not with short leg braces.


28. A client injures his spinal cord in a driving accident. The nurse knows
that the client will be unable to breathe spontaneously if the injury site is
above which vertebral level?

  A.   C4
  B.   C5
  C.   C6
  D.   C7

Correct Answer: 1
RATIONALES: A client with a spinal cord injury above the level of the
fourth cervical vertebra (C4) can't breathe spontaneously. With an injury
below this level, diaphragmatic breathing occurs. An injury from C5 to
C6 results in quadriplegia, with diaphragmatic breathing and gross arm
movements.



29. The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all
of the following steps except:




  A. position the client to prevent airway obstruction.

  B. keep the client in one position to decrease bleeding.

  C. administer I.V. fluid as ordered and monitor the client for signs of fluid
      volume excess.

  D. maintain the client in a quiet environment.



Correct Answer: B

RATIONALES: The nurse shouldn't keep the client in one position but rather
carefully reposition the client often (at least every hour). The client needs to
be positioned so that a patent airway can be maintained. Fluid administration
must be closely monitored to prevent complications such as increased
intracranial pressure. The client must be maintained in a quiet environment to
decrease the risk of rebleeding.




30. A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the
appropriate choice for this client?




  A. A private room down the hall from the nurses' station

  B. An isolation room close to the nurses' station

  C. A semiprivate room with a 32-year-old client who has viral meningitis

  D. A two-bed room with a client who previously had bacterial meningitis
   Correct Answer:B

   RATIONALES: A client with bacterial meningitis should be kept in isolation for
   at least 24 hours after admission and, during the initial acute phase, should be
   as close to the nurses' station as possible to allow maximal observation.
   Placing the client in a room with a client who has viral meningitis may cause
   harm to both clients because the organisms causing viral and bacterial
   meningitis differ; either client may contract the other's disease. Immunity to
   bacterial meningitis can't be acquired; therefore, a client who previously had
   bacterial meningitis shouldn't be put at risk by rooming with a client who has
   just been diagnosed with this disease.




   31. The nurse is teaching a client with a T4 spinal cord injury and paralysis of the lower
   extremities how to transfer from the bed to a wheelchair. The nurse should instruct the client to
   move:

     A. his upper and lower body into the wheelchair simultaneously.

     B. his upper body to the wheelchair first.
     C. his feet to the wheelchair pedals and then his hands to the wheelchair
        arms.
     D. his feet to the floor and then his buttocks to the wheelchair seat.

   Correct Answer: B
   RATIONALES: When transferring from a bed to a wheelchair, a client
   with paralysis of the lower extremities should move the strong part of his
   body to the chair first. Therefore, the client should move his upper body
   to the chair and then move his legs from the bed to the chair. The other
   techniques aren't safe for the client.




A client with quadriplegia is in spinal shock. What
should the nurse expect?

  A. Absence of reflexes along with flaccid extremities
         B. Positive Babinski's reflex along with spastic extremities
         C. Hyperreflexia along with spastic extremities
         D. Spasticity of all four extremities

       Correct Answer: A
       RATIONALES: During the period immediately following a spinal cord injury,
       spinal shock occurs. In spinal shock, all reflexes are absent and the extremities
       are flaccid. When spinal shock subsides, the client will demonstrate positive
       Babinski's reflex, hyperreflexia, and spasticity of all four extremities.




    The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache.
    Which action should the nurse perform first?




      A. Sit with the client for a few minutes.

      B. Administer an analgesic.

      C. Inform the nurse-manager.

      D. Call the physician immediately.



    Correct Answer: D

    RATIONALES: The headache may be an indication that the aneurysm is leaking. The nurse
    should notify the physician immediately. Sitting with the client is appropriate but only after the
    physician has been notified of the change in the client's condition. The physician will decide
    whether or not administration of an analgesic is indicated. Informing the nurse-manager isn't
    necessary.




A client is thrown from an automobile during a collision. The nurse knows that the client will be
able to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what
vertebral level?
  A.   C4
  B.   C5
  C.   C3
  D.   C7

Correct Answer: B
RATIONALES: A client with a spinal cord injury at or above the level of the fourth cervical
vertebra (C4) can't breathe spontaneously. With an injury below this level, diaphragmatic
breathing occurs. An injury from C5 to C6 results in quadriplegia, with diaphragmatic
breathing and gross arm movements.

				
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