ATI MEDSURG 2 NUR 265/ DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE

NUR 265 Neuro-Shock &

Burns practice

Created on:11/26/2018 Page 1

1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected

cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that

apply.)

A. Hypotension

B. Polyuria

C. Hyperthermia

D. Absence of bowel sounds

E. Weakened gag reflex

Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood

pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately

perfuse the spinal cord.

Polyuria is incorrect. The nurse should check the

client for bladder distention and inability to urinate due to ineffective function of the bladder

muscles.

Hyperthermia is incorrect. The nurse should monitor the client for

hypothermia caused by a lack of lack of sympathetic input.

Absence of bowel

sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client

to develop a paralytic ileus.

Weakened gag reflex is correct. The nurse should

monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which

of the following statements by the client indicates a need for further teaching?

A. "I will notify my doctor before taking any other medications."

Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should be

notified that the client is taking phenytoin.

B. "I have made an appointment to see my dentist next week."

Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dental

monitoring important.

C. "I know that I cannot switch brands of this medication."

Rationale: The client understands that bioavailability varies with different brands, so no substitutions should

be made.

D. "I'll be glad when I can stop taking this medicine."

Rationale: Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant

medications commonly require them for lifetime administration, and phenytoin should not be

stopped without the advice of the client's provider.

3. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new

NUR 265 Neuro-Shock &

Burns practice

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prescription for timolol eye drops. Which of the following instructions should the nurse provide?

A. The medication is to be applied when the client is experiencing eye pain.

Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserve

remaining eyesight.

B. The medication will be used until the client's intraocular pressure returns to normal.

Rationale: Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen the

client's condition.

C. The medication should be applied on a regular schedule for the rest of the client's life.

Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or

decrease its production, or both. The client must continue the eye drops on an uninterrupted

basis for life to maintain intraocular pressure at an acceptable level.

D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.

Rationale: Treatment for open-angle glaucoma is to continue for life.

4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions

should the nurse take first?

A. Turn the client's head to the side.

Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to

client care is to turn the client's head to the side. This action keeps the client's airway clear of

secretion to prevent aspiration.

B. Check the client's motor strength.

Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment

following the seizure; however, there is another action the nurse should take first.

C. Loosen the clothing around the client's waist.

Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;

however, there is another action the nurse should take first.

D. Document the time the seizure began.

Rationale: The nurse should document the time the seizure began and ended to provide information to the

provider about the severity of the seizure; however, there is another action the nurse should take

first.

5. A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the

nurse report to the client's provider?

A. "My eye really itches, but I'm trying not to rub it."

Rationale:

NUR 265 Neuro-Shock &

Burns practice

Created on:11/26/2018 Page 3

Itching is common after cataract surgery. The nurse should remind the client not to rub or place

pressure on the eyes.

B. "I need something for the pain in my eye. I can't stand it."

Rationale: Following cataract surgery, the client should expect only mild pain and should immediately

report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after

surgery might indicate increased intraocular pressure or hemorrhage.

C. "It's hard to see with a patch on one eye. I'm afraid of falling."

Rationale: Clients who wear an eye patch lose their depth perception and part of their peripheral vision,

temporarily decreasing visual acuity.

D. "The bright light in this room is really bothering me."

Rationale: The client may find that exposure to bright light is uncomfortable after cataract surgery. Wearing

sunglasses can prevent most of the client's discomfort.

6. A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While

assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the

following should be the nurse’s initial action?

A. Document the amount of drainage.

Rationale: The nurse should document the amount of drainage along with the clarity to determine the

extent of the cerebral spinal fluid (CSF) leakage and the presence of blood or pus; however

there is another action that is priority.

B. Obtain a culture of the drainage.

Rationale: Although infection is a potential complication of the procedure, there is another action that is

priority.

C. Check the drainage for glucose.

Rationale: A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage

from the nose is a sign that this complication has occurred. The first action the nurse should take

using the nursing process is to assess the drainage for the presence of glucose, which would

indicate that the drainage is CSF.

D. Notify the client's provider.

Rationale: Although the provider should be notified of the findings, there is another action that is priority.

7. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the

following parameters should the nurse use first in order to assess the client's pain level?

A. pulse and blood pressure findings

Rationale: The nurse should assess the client's pain level routinely along with vital signs. A pain

NUR 265 Neuro-Shock &

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assessment should also be completed if the client has a change in condition, such as a new

onset of chest pain, or following a procedure which can be uncomfortable for the client, such as

x-rays which require the client to lay on a hard surface for extended periods of time. A

hierarchical method of pain assessment is recommended when caring for clients who may have

difficulty expressing themselves. Although vital signs can be used as a physiologic indicator,

monitoring them is an objective method of evaluating pain and may not be a reliable means of

assessing pain levels. Evidence-based practice indicates the nurse should use a different

parameter first.

B. behavioral indicators and effect

Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may

have difficulty expressing themselves. Although behavioral indicators can be used, the nurse

should recognize that pain behaviors are unique to each patient. Evidence-based practice

indicates the nurse should use a different parameter first.

C. scheduled treatments and client illness

Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may

have difficulty expressing themselves. Although treating a client based upon the client’s

condition or based upon the client’s scheduled, potentially painful procedure will yield effective

results at assessing pain levels, evidence-based practice indicates the nurse should use a

different parameter first.

D. a self-report pain rating scale

Rationale: Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech

problem. The client who has expressive aphasia is able to understand what is said but is unable

to communicate verbally. However, this does not necessarily mean that a client is unable to

reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain

the client’s self- report of pain. When assessing a client for pain, the nurse should utilize the

hierarchy of pain measures which begins with self-report. It is always better to use a subjective

method, such as a client report, instead of an objective method, such as something that is

observable by the nurse, which is much less reliable.

8. A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following

actions is most likely to facilitate resolution of the headache?

A. Administer pain medication.

Rationale: A spinal headache following a lumbar puncture develops due to a leaking of the cerebrospinal

fluid (CSF) which depletes the amount of circulating CSF and results in insufficient fluid to

maintain the mechanical stability of the brain. While a medication for pain may help control the

symptoms, it doesn't facilitate resolution of the headache.

B. Darken the client's room and close the door.

Rationale: The client who has a spinal headache experiences a throbbing headache that worsens with

sitting or standing and is the result of a decreased amount of circulating CSF. Darkening the

room and closing the door may assist in controlling the pain for the client who has a migraine,

but it is not useful in the client who has a spinal headache.

C. Increase fluid intake.

Rationale: