ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 43 : Care of Patients with Problems of the CNS: The Spinal Cord Questions
Question 1 of 5
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
Correct Answer: C
Rationale: The client is manifesting symptoms of autonomic dysreflexia, likely due to bladder distention. Palpating the bladder to check for distention is the first step to identify and address the cause. The other actions are not appropriate as initial responses.
Question 2 of 5
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
Correct Answer: D
Rationale: The first priority for a client with a cervical spinal cord injury is to assess respiratory status and airway patency, as these injuries can compromise breathing. Other assessments follow after ensuring airway and breathing are stable.
Question 3 of 5
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?
Correct Answer: B
Rationale: Methylprednisolone is administered within the first 8 hours of a spinal cord injury to reduce inflammation and improve motor and sensory function. The other medications are not indicated for acute spinal cord injury.
Question 4 of 5
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching?
Correct Answer: C
Rationale: In clients with lower motor neuron injuries, performing a Valsalva maneuver by tightening abdominal muscles can stimulate urine flow. The other options are not effective for achieving bladder control in this context.
Question 5 of 5
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
Correct Answer: C
Rationale: Fingolimod (Gilenya) can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not typical adverse effects of this medication.