NUR242 EXAM 4 STUDY NOTES |
COMPLETE SUMMARY | LATEST 2025/2026
| 100% PASS GUARANTEED
1. Normal BP - ANSWER Systolic <120 / Diastolic <80
2. Pre-HTN - ANSWER Systolic =120-139 / Diastolic=80-89
3. Stage 1 HTN - ANSWER Systolic=140-159 / Diastolic=90-99
4. Stage 2 HTN - ANSWER Systolic=>160 / Diastolic=>100
5. Malignant HTN - ANSWER Extremely high BP >180/110
6. Which assessment findings alert the nurse that the client who has a spinal
cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)?
- ANSWER Hypertension and bradycardia
,7. Which is the priority focus of nursing care for a client with a spinal cord
injury during the immediate postinjury period? - ANSWER Avoiding
flexion or hyperextension of the spine
8. The nurse is caring for a client 1 week after the client experienced a spinal
cord injury at the T3 level. Which short-term goal is appropriate in planning
care for this client? - ANSWER The client will carry out personal hygiene
activities.
9. Which mechanism of injury might be the reason for a suspected spinal cord
injury in a client with a direct injury to the vertebral column from a gunshot
after a mass shooting? - ANSWER Penetrating trauma
10.The primary reason the nurse encourages a client with a spinal cord injury to
increase oral fluid intake is to prevent which problem? -
ANSWER urinary tract infections
11.When providing care for a client with paraplegia secondary to a spinal cord
injury, which potential complication may occur early during the recovery
period? - ANSWER bladder control
12.The nurse plans to monitor for signs of autonomic dysreflexia in a client
who sustained a spinal cord injury at the T2 level. Which statement explains
the nurse's rational? - ANSWER There is damage above the sixth thoracic
vertebra.
13.Which explanation would the nurse provide family members who ask the
meaning of their loved one's diagnosis of "paraplegia" after experiencing a
, spinal cord injury? - ANSWER The client's lower extremities are
paralyzed
14.Which intervention would the nurse perform first for a client with a spinal
cord injury who is experiencing autonomic dysreflexia? -
ANSWER Place the client in sitting position.
15.The nurse is providing care to a client. Which nursing action has the highest
priority when the nurse is moving a client with a neck and spinal cord injury
during the assessment process? - ANSWER Implementing the logrolling
technique
16.Which nursing action is a priority for a client with a spinal cord injury who
has developed sudden autonomic dysreflexia? - ANSWER to place in a
sitting position
17.Which priority intervention would the nurse perform immediately for a
client with a spinal cord injury? - ANSWER Immobilize and stabilize the
cervical spine.
18.Which procedure may benefit the client who was in a traffic accident, is
choking, and may have a spinal cord injury? - ANSWER Performing a
jaw-thrust maneuver
19.The nurse is caring for a client who has paraplegia as a result of a spinal
cord injury. Which rehabilitation plan will be effective for this client? -
ANSWER The plan is formulated and implemented early in the client's
care
, 20.When a client is admitted to the emergency department with a possible
spinal cord injury, the nurse would monitor for which clinical manifestations
of spinal shock? Select all that apply. One, some, or all responses may be
correct. - ANSWER Bradycardia, hypotension, urinary retention
21.Which factor contributes to skeletal calcium loss by a client who has
paraplegia? - ANSWER Decreased weight bearing
22.Which item in the plan of care for a client with paraplegia would the nurse
question? - ANSWER instruct the client to do active leg exercises.
23.Which action is likely to help prevent pressure injuries for a client who has
paraplegia? - ANSWER Inspecting the skin every day
24.Which rationale supports the nursing intervention to turn the client with
paraplegia every 1 to 2 hours? - ANSWER To prevent development of
pressure injuries
25.The nurse writes a goal of preventing renal calculi in a care plan for a client
who has paraplegia. Which information provides the rationale for selecting
this goal? - ANSWER Accelerated bone demineralization
26.Which condition would the nurse suspect in an emergency department client
with C8 tetraplegia, blood pressure of 80/40 mm Hg, pulse of 48 beats per
minute, and respiratory rate (RR) of 18 breaths per minute? -
ANSWER Neurogenic shock
COMPLETE SUMMARY | LATEST 2025/2026
| 100% PASS GUARANTEED
1. Normal BP - ANSWER Systolic <120 / Diastolic <80
2. Pre-HTN - ANSWER Systolic =120-139 / Diastolic=80-89
3. Stage 1 HTN - ANSWER Systolic=140-159 / Diastolic=90-99
4. Stage 2 HTN - ANSWER Systolic=>160 / Diastolic=>100
5. Malignant HTN - ANSWER Extremely high BP >180/110
6. Which assessment findings alert the nurse that the client who has a spinal
cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)?
- ANSWER Hypertension and bradycardia
,7. Which is the priority focus of nursing care for a client with a spinal cord
injury during the immediate postinjury period? - ANSWER Avoiding
flexion or hyperextension of the spine
8. The nurse is caring for a client 1 week after the client experienced a spinal
cord injury at the T3 level. Which short-term goal is appropriate in planning
care for this client? - ANSWER The client will carry out personal hygiene
activities.
9. Which mechanism of injury might be the reason for a suspected spinal cord
injury in a client with a direct injury to the vertebral column from a gunshot
after a mass shooting? - ANSWER Penetrating trauma
10.The primary reason the nurse encourages a client with a spinal cord injury to
increase oral fluid intake is to prevent which problem? -
ANSWER urinary tract infections
11.When providing care for a client with paraplegia secondary to a spinal cord
injury, which potential complication may occur early during the recovery
period? - ANSWER bladder control
12.The nurse plans to monitor for signs of autonomic dysreflexia in a client
who sustained a spinal cord injury at the T2 level. Which statement explains
the nurse's rational? - ANSWER There is damage above the sixth thoracic
vertebra.
13.Which explanation would the nurse provide family members who ask the
meaning of their loved one's diagnosis of "paraplegia" after experiencing a
, spinal cord injury? - ANSWER The client's lower extremities are
paralyzed
14.Which intervention would the nurse perform first for a client with a spinal
cord injury who is experiencing autonomic dysreflexia? -
ANSWER Place the client in sitting position.
15.The nurse is providing care to a client. Which nursing action has the highest
priority when the nurse is moving a client with a neck and spinal cord injury
during the assessment process? - ANSWER Implementing the logrolling
technique
16.Which nursing action is a priority for a client with a spinal cord injury who
has developed sudden autonomic dysreflexia? - ANSWER to place in a
sitting position
17.Which priority intervention would the nurse perform immediately for a
client with a spinal cord injury? - ANSWER Immobilize and stabilize the
cervical spine.
18.Which procedure may benefit the client who was in a traffic accident, is
choking, and may have a spinal cord injury? - ANSWER Performing a
jaw-thrust maneuver
19.The nurse is caring for a client who has paraplegia as a result of a spinal
cord injury. Which rehabilitation plan will be effective for this client? -
ANSWER The plan is formulated and implemented early in the client's
care
, 20.When a client is admitted to the emergency department with a possible
spinal cord injury, the nurse would monitor for which clinical manifestations
of spinal shock? Select all that apply. One, some, or all responses may be
correct. - ANSWER Bradycardia, hypotension, urinary retention
21.Which factor contributes to skeletal calcium loss by a client who has
paraplegia? - ANSWER Decreased weight bearing
22.Which item in the plan of care for a client with paraplegia would the nurse
question? - ANSWER instruct the client to do active leg exercises.
23.Which action is likely to help prevent pressure injuries for a client who has
paraplegia? - ANSWER Inspecting the skin every day
24.Which rationale supports the nursing intervention to turn the client with
paraplegia every 1 to 2 hours? - ANSWER To prevent development of
pressure injuries
25.The nurse writes a goal of preventing renal calculi in a care plan for a client
who has paraplegia. Which information provides the rationale for selecting
this goal? - ANSWER Accelerated bone demineralization
26.Which condition would the nurse suspect in an emergency department client
with C8 tetraplegia, blood pressure of 80/40 mm Hg, pulse of 48 beats per
minute, and respiratory rate (RR) of 18 breaths per minute? -
ANSWER Neurogenic shock
