NUR 417 Med Surg Final Exam Questions
With Correct Answers
To prevent autonomic dysreflexia, which nursing action should the home health
| | | | | | | | | | |
nurse include in the plan of care for a patient who
| | | | | | | | | |
has paraplegia at the T4 level? - CORRECT ANSWER✔✔-Assist to plan a
| | | | | | | | | | | |
prescribed bowel program. | |
The nurse is admitting a patient who has a neck fracture at the C6 level to the
| | | | | | | | | | | | | | | | |
intensive care unit. Which finding on the nursing
| | | | | | |
assessment is congruent with neurogenic shock? - CORRECT ANSWER✔✔-
| | | | | | | |
Hypotension and warm extremities | | |
What should the nurse explain to the patient who has a T2 spinal cord
| | | | | | | | | | | | | |
transection injury? - CORRECT ANSWER✔✔-Function of both arms should be
| | | | | | | | | |
maintained.
What should the nurse include in a rehabilitation plan as an appropriate goal for
| | | | | | | | | | | | | |
a 30-yr-old patient with a C6 spinal cord injury? - CORRECT ANSWER✔✔-Propel a
| | | | | | | | | | | | |
manual wheelchair on a flat surface.
| | | | |
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic
| | | | | | | | | | | | | |
reflexic bladder. Which action should the nurse
| | | | | |
,include in the plan of care? - CORRECT ANSWER✔✔-Instruct the patient how to
| | | | | | | | | | | | |
self-catheterize.
A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the
| | | | | | | | | | | | | | |
nurse, "I want to be transferred to a hospital where
| | | | | | | | |
the nurses know what they are doing." Which action should the nurse
| | | | | | | | | | | |
appropriately take? - CORRECT ANSWER✔✔-Ask the patient to provide input for
| | | | | | | | | | |
the plan of care.
| | |
A 38-yr-old patient who has had a spinal cord injury returned home following a
| | | | | | | | | | | | | |
stay in a rehabilitation facility. The home care
| | | | | | |
nurse notes the spouse is performing many of the activities that the patient had
| | | | | | | | | | | | | |
been managing unassisted during rehabilitation.
| | | |
What should the nurse identify as the most appropriate action at this phase of
| | | | | | | | | | | | | |
rehabilitation? - CORRECT ANSWER✔✔-Develop a plan to increase the patient's | | | | | | | | | |
independence in consultation with the | | | |
patient and the spouse. | | |
Which action should the nurse recognize has the highest priority for a patient
| | | | | | | | | | | | |
who was admitted 16 hours earlier with a C5 spinal
| | | | | | | | |
cord injury? - CORRECT ANSWER✔✔-Assessment of respiratory rate and effort
| | | | | | | | |
A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and
| | | | | | | | | | | | | | | | |
crackles. What initial intervention should the
| | | | | |
nurse perform? - CORRECT ANSWER✔✔-Push upward on the epigastric area as
| | | | | | | | | | |
the patient coughs.
| |
, A patient with a history of T3 spinal cord injury is admitted with dermal ulcers.
| | | | | | | | | | | | | | |
The patient tells the nurse, "I have a pounding
| | | | | | | |
headache and I feel sick to my stomach." Which action should the nurse take
| | | | | | | | | | | | | |
first? - CORRECT ANSWER✔✔-Assess the blood pressure (BP).
| | | | | | |
A patient with a T4 spinal cord injury asks the nurse if he will be able to be
| | | | | | | | | | | | | | | | | |
sexually active. Which information should the nurse
| | | | | |
include in an initial response? - CORRECT ANSWER✔✔-Multiple options are
| | | | | | | | | |
available to maintain sexuality after spinal cord injury.
| | | | | | |
Which collaborative and nursing actions should the nurse include in the plan of
| | | | | | | | | | | | |
care for a patient who experienced a T2 spinal cord
| | | | | | | | |
transection 24 hours ago? (Select all that apply.) - CORRECT ANSWER✔✔-Urinary
| | | | | | | | | | |
catheter care |
Continuous cardiac monitoring | |
Administration of H2 receptor blockers | | | |
Maintenance of a warm room temperature | | | | |
In which order should the nurse perform the following actions for a patient
| | | | | | | | | | | | |
admitted to the emergency department with possible C5
| | | | | | |
spinal cord trauma? (Put a comma and a space between each answer choice [A,
| | | | | | | | | | | | | |
B, C, D, E].) - CORRECT ANSWER✔✔-a. Infuse normal saline at 150 mL/hr.
| | | | | | | | | | | |
b. Monitor cardiac rhythm and blood pressure.
| | | | | |
c. Administer O2 using a non-rebreather mask.
| | | | | |
d. Immobilize the patient's head, neck, and spine.
| | | | | | |
e. Transfer the patient to radiology for spinal computed tomography (CT).
| | | | | | | | | |
With Correct Answers
To prevent autonomic dysreflexia, which nursing action should the home health
| | | | | | | | | | |
nurse include in the plan of care for a patient who
| | | | | | | | | |
has paraplegia at the T4 level? - CORRECT ANSWER✔✔-Assist to plan a
| | | | | | | | | | | |
prescribed bowel program. | |
The nurse is admitting a patient who has a neck fracture at the C6 level to the
| | | | | | | | | | | | | | | | |
intensive care unit. Which finding on the nursing
| | | | | | |
assessment is congruent with neurogenic shock? - CORRECT ANSWER✔✔-
| | | | | | | |
Hypotension and warm extremities | | |
What should the nurse explain to the patient who has a T2 spinal cord
| | | | | | | | | | | | | |
transection injury? - CORRECT ANSWER✔✔-Function of both arms should be
| | | | | | | | | |
maintained.
What should the nurse include in a rehabilitation plan as an appropriate goal for
| | | | | | | | | | | | | |
a 30-yr-old patient with a C6 spinal cord injury? - CORRECT ANSWER✔✔-Propel a
| | | | | | | | | | | | |
manual wheelchair on a flat surface.
| | | | |
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic
| | | | | | | | | | | | | |
reflexic bladder. Which action should the nurse
| | | | | |
,include in the plan of care? - CORRECT ANSWER✔✔-Instruct the patient how to
| | | | | | | | | | | | |
self-catheterize.
A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the
| | | | | | | | | | | | | | |
nurse, "I want to be transferred to a hospital where
| | | | | | | | |
the nurses know what they are doing." Which action should the nurse
| | | | | | | | | | | |
appropriately take? - CORRECT ANSWER✔✔-Ask the patient to provide input for
| | | | | | | | | | |
the plan of care.
| | |
A 38-yr-old patient who has had a spinal cord injury returned home following a
| | | | | | | | | | | | | |
stay in a rehabilitation facility. The home care
| | | | | | |
nurse notes the spouse is performing many of the activities that the patient had
| | | | | | | | | | | | | |
been managing unassisted during rehabilitation.
| | | |
What should the nurse identify as the most appropriate action at this phase of
| | | | | | | | | | | | | |
rehabilitation? - CORRECT ANSWER✔✔-Develop a plan to increase the patient's | | | | | | | | | |
independence in consultation with the | | | |
patient and the spouse. | | |
Which action should the nurse recognize has the highest priority for a patient
| | | | | | | | | | | | |
who was admitted 16 hours earlier with a C5 spinal
| | | | | | | | |
cord injury? - CORRECT ANSWER✔✔-Assessment of respiratory rate and effort
| | | | | | | | |
A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and
| | | | | | | | | | | | | | | | |
crackles. What initial intervention should the
| | | | | |
nurse perform? - CORRECT ANSWER✔✔-Push upward on the epigastric area as
| | | | | | | | | | |
the patient coughs.
| |
, A patient with a history of T3 spinal cord injury is admitted with dermal ulcers.
| | | | | | | | | | | | | | |
The patient tells the nurse, "I have a pounding
| | | | | | | |
headache and I feel sick to my stomach." Which action should the nurse take
| | | | | | | | | | | | | |
first? - CORRECT ANSWER✔✔-Assess the blood pressure (BP).
| | | | | | |
A patient with a T4 spinal cord injury asks the nurse if he will be able to be
| | | | | | | | | | | | | | | | | |
sexually active. Which information should the nurse
| | | | | |
include in an initial response? - CORRECT ANSWER✔✔-Multiple options are
| | | | | | | | | |
available to maintain sexuality after spinal cord injury.
| | | | | | |
Which collaborative and nursing actions should the nurse include in the plan of
| | | | | | | | | | | | |
care for a patient who experienced a T2 spinal cord
| | | | | | | | |
transection 24 hours ago? (Select all that apply.) - CORRECT ANSWER✔✔-Urinary
| | | | | | | | | | |
catheter care |
Continuous cardiac monitoring | |
Administration of H2 receptor blockers | | | |
Maintenance of a warm room temperature | | | | |
In which order should the nurse perform the following actions for a patient
| | | | | | | | | | | | |
admitted to the emergency department with possible C5
| | | | | | |
spinal cord trauma? (Put a comma and a space between each answer choice [A,
| | | | | | | | | | | | | |
B, C, D, E].) - CORRECT ANSWER✔✔-a. Infuse normal saline at 150 mL/hr.
| | | | | | | | | | | |
b. Monitor cardiac rhythm and blood pressure.
| | | | | |
c. Administer O2 using a non-rebreather mask.
| | | | | |
d. Immobilize the patient's head, neck, and spine.
| | | | | | |
e. Transfer the patient to radiology for spinal computed tomography (CT).
| | | | | | | | | |
