ATI RN
Questions to Ask About the Neurological System Questions
Question 1 of 5
Which of the following actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with neurologic deficit?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Measure intake and output. Monitoring intake and output is crucial in assessing electrolyte imbalances and dehydration in clients with neurologic deficits. Neurologic conditions can impact the body's ability to regulate fluid and electrolyte balance, making these clients more susceptible to imbalances. Option B) Use the Glasgow Coma Scale is incorrect as it is a tool used to assess a patient's level of consciousness and is not directly related to monitoring for electrolyte imbalances or dehydration. Option C) Mini-Mental Status Examination is a cognitive assessment tool used to evaluate cognitive function and is not specific to monitoring fluid and electrolyte status in clients with neurologic deficits. Option D) Assess vital signs is important in the overall assessment of a client, but it may not provide specific information about electrolyte imbalances and dehydration unless significant changes are already present. Educational Context: Nurses caring for clients with neurologic deficits need to have a comprehensive understanding of how these conditions can impact the body's homeostasis, including fluid and electrolyte balance. Monitoring intake and output is a fundamental nursing skill that helps in early detection of imbalances, allowing for prompt interventions to prevent complications. Understanding the rationale behind each assessment helps nurses provide holistic care to their clients and enhance patient outcomes.
Question 2 of 5
A patient is admitted to the hospital with Guillain-Barré syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, what should the nurse know about Guillain-Barré syndrome?
Correct Answer: A
Rationale: The correct answer is A) The most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity. During the acute phase of Guillain-Barré syndrome, patients are at high risk for respiratory compromise due to muscle weakness, particularly affecting the diaphragm. Monitoring these respiratory parameters is crucial for early detection of respiratory distress and the need for interventions such as mechanical ventilation. Option B is incorrect because early treatment with corticosteroids is not recommended for Guillain-Barré syndrome as it can worsen the condition by suppressing the immune response needed for recovery. Option C is incorrect as the most serious complication is paralysis due to ascending muscle weakness, not ascending demyelination. Option D is incorrect because Guillain-Barré syndrome can affect both voluntary and autonomic nervous systems, leading to potential complications like fluctuations in heart rate and blood pressure. In an educational context, understanding the importance of respiratory monitoring in Guillain-Barré syndrome highlights the critical role nurses play in the care of these patients. By closely monitoring respiratory status, nurses can intervene promptly and prevent respiratory failure, ultimately improving patient outcomes.
Question 3 of 5
What is one indication for early surgical therapy of the patient with a spinal cord injury?
Correct Answer: D
Rationale: The correct answer is D) Evidence of continued compression of the cord is apparent. Early surgical therapy in patients with spinal cord injury is crucial when there is ongoing compression of the spinal cord. This compression can lead to further damage and worsening neurological deficits if not addressed promptly. Surgical intervention aims to relieve the pressure on the spinal cord, stabilize the spine, and prevent secondary injuries. Option A) There is incomplete cord lesion involvement: While this may be a consideration in the overall management of spinal cord injury, it is not a specific indication for early surgical therapy. Option B) The ligaments that support the spine are torn: While this may indicate instability in the spine and require surgical intervention, it is not a direct indication for early surgery in the context of spinal cord injury. Option C) A high cervical injury causes loss of respiratory function: While loss of respiratory function is a serious complication of high cervical spinal cord injury, it does not necessarily indicate the need for immediate surgical intervention unless there is evidence of cord compression. Educational Context: Understanding the rationale for early surgical therapy in spinal cord injury is essential for healthcare providers caring for these patients. Prompt recognition of indications for surgery can lead to better outcomes and prevent further neurological deterioration. It is crucial to consider the specific criteria that warrant surgical intervention to provide optimal care for patients with spinal cord injuries.
Question 4 of 5
An older patient is describing increased rigidity in the shoulders, back, and hips. The loss of elasticity in what tissue contributes to this?
Correct Answer: D
Rationale: The correct answer is D) Cartilage. Cartilage is a connective tissue found in joints between bones, providing cushioning and facilitating smooth movement. As a person ages, cartilage can degenerate, leading to increased rigidity and decreased flexibility in the joints. This is a common phenomenon in conditions like osteoarthritis. Option A) Actin and C) Myosin are proteins found in muscle fibers and are involved in muscle contraction, not in the structure of joints or flexibility of tissues. Option B) Fascia is a connective tissue that surrounds muscles and other structures, providing support and protection. While fascia plays a role in movement and flexibility, it is not the primary tissue responsible for the loss of elasticity described in the scenario. Educationally, understanding the role of different tissues in the body is crucial for healthcare professionals in assessing and managing conditions affecting the musculoskeletal system. Recognizing the impact of aging on cartilage and joint health can help in early detection and intervention to improve quality of life for older patients.
Question 5 of 5
When assessing the patient the nurse notices that the patient has footdrop and the foot slaps down on the floor as the patient walks. How does the nurse document this gait?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Steppage gait. A steppage gait is characterized by the foot dropping down due to weakness of the dorsiflexor muscles, resulting in the toes dragging or scraping on the ground and the foot slapping down during the swing phase of the gait cycle. This is commonly seen in individuals with footdrop, a condition where they are unable to lift the front part of the foot. Option A) Ataxic gait is characterized by a wide-based, staggering, unsteady gait often seen in individuals with cerebellar dysfunction. This does not align with the symptoms described in the question. Option B) Spastic gait is characterized by stiff, jerky movements due to increased muscle tone, commonly seen in conditions like cerebral palsy or stroke. This does not fit the description given. Option C) Antalgic gait refers to a gait pattern that is altered due to pain, where the individual avoids putting weight on a specific limb. This is not the case in the scenario described. Understanding different gait patterns is vital for healthcare professionals, especially nurses, as it provides valuable information about a patient's neurological and musculoskeletal status. Recognizing specific gait abnormalities can help in identifying underlying conditions, determining appropriate interventions, and collaborating effectively with the healthcare team.