20815213
Descripción
Test por Esmeralda Espitia, actualizado hace más de 1 año
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Creado por Esmeralda Espitia
hace casi 5 años
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Pregunta 1
Pregunta
A client has suffered a spinal cord injury after a fall. When he is brought in for care, the client experiences diaphoresis and headache. The nurse notes that his blood pressure is 174/102 mmHg. Which action should the nurse perform first?
Respuesta
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Raise the head of the bed, lower the legs, and remove constrictive clothing
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Apply hemodynamic monitoring
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Ask the client to perform the Valsalva maneuver
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Assess the client for fecal impaction
Pregunta 2
Pregunta
A 22-year-old client has suffered a spinal cord injury in which he is experiencing spinal shock and cannot feel his legs. Twenty-four hours after the injury, the client tells the nurse, “This will be good for me. I can handle this and I’m doing fine.” Which response from the nurse is most likely indicated?
Respuesta
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Ask the client if he would like to speak with a spiritual advisor or social worker
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Continue to treat the client as is but remind him that he may never walk again
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Make arrangements for the client to be discharged to home
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Document the client's positive attitude regarding this life-changing disability
Pregunta 3
Pregunta
A client with a spinal cord injury has difficulty determining when the bladder needs emptied. The nurse teaches the client about tapping to stimulate voiding. How would the nurse describe tapping to this client?
Respuesta
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The area over the bladder is tapped to stimulate the bladder muscles
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The client bears down to increase pressure and then taps the base of the abdomen to release urine
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The client wears a device that acts as a tap or faucet to stop and start urine flow
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The client alternately taps the abdomen and the back to signal messages across the body to promote urination
Pregunta 4
Pregunta
The most appropriate prevention against spinal cord injury is which of the following actions?
Respuesta
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Use seat belts in the car
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Avoid horseback riding without a helmet
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Avoid surfing
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Drink in moderation before driving
Pregunta 5
Pregunta
The nurse knows that a client suffering from complete paralysis from the waist down would have the condition of which of the following?
Respuesta
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Hemiparesis
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Hemiplegia
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Paraparesis
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Paraplegia
Pregunta 6
Pregunta
The nurse is on a rapid response team that has responded to a code blue. The victim is a visitor who has fallen down a flight of stairs and is unresponsive. A cervical spine injury is suspected. In order to perform CPR safely, what is the best initial intervention?
Respuesta
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Jaw thrust maneuver
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Chin tilt maneuver
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Nasotracheal intubation
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Cricothyroidotomy
Pregunta 7
Pregunta
A client has suffered a spinal cord injury after a diving accident. When first brought to the emergency room, the client is suffering from spinal shock. Which symptoms best describe this condition?
Respuesta
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Flaccid paralysis and anesthesia in the lower extremities
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Hypertension, headache, and blurred vision
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Back pain, muscle spasms, and difficulty walking
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Decreased venous return and skin breakdown in the extremities
Pregunta 8
Pregunta
The client has a spinal cord injury and is suffering from spinal shock. Which of the following is an expected symptom in spinal shock?
Respuesta
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Bradycardia
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Spasticity
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Increased visceral reflexes
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Hypertension
Pregunta 9
Pregunta
A client is being seen in the emergency department after a spinal cord injury. The client initially states an inability to feel anything below the shoulders. At which point would this client need to be intubated with an endotracheal tube?
Respuesta
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The point at which the client has a Glasgow Coma Score of 8
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The point at which the client has a respiratory rate of 10/minute
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The point at which the client's oxygen saturation is 88 percent on room air
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Upon discovering that the client has a pneumothorax as seen on x-ray
Pregunta 10
Pregunta
The nursing care plan of a client with spinal cord injury should include which of the following? Select all that apply.
Respuesta
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Maintain stable vital signs
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Provide skeletal traction
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Prepare client for surgical stabilization of spine
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Begin aggressive steroid therapy
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Administer antispasmodics
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