MSN377 EXAM4 QUESTIONS AND VERIFIED
ANSWERS LATEST UPDATE//ALREADY GRADED A+
the nurse advises a patient with myasthenia gravis to
A. perform physically demanding activities early in the day
B. anticipate the need for weekly plasmapheresis treatments
C. do frequent weight-bearing exercise to prevent muscle atrophy
D. protect the extremities from injury due to poor sensory perception -
(answer)A. perform physically demanding activities early in the day
To prevent autonomic hyperreflexia, which nursing action will the home health
nurse include in the plan of care for a patient who has paraplegia at the T4 level?
A. support selection of a high-protein diet
B. discuss options for sexuality and fertility
C. assist in planning a prescribed bowel program
D. use quad coughing to strengthen cough efforts - (answer)C. assist in planning a
prescribed bowel program
which assessment data for a patient who has Guillain-Barre syndrome will require
the nurses most immediate action?
A. the patients sacral area skin is reddened
B. the patient is continuously drooling saliva
C. the patient complains of severe pain in the feet
D. the patients blood pressure is 150/82 - (answer)B. the patient is continuously
drooling saliva
,The nurse has administered a prescribed IV osmotic diuretic to an unconscious
patient. which parameter should the nurse monitor to determine the medications
effectiveness?
A. blood pressure
B. intracranial pressure
C. oxygen saturation
D. hemoglobin and hematocrit - (answer)B. intracranial pressure
A patient who is unconscious has ineffective cerebral tissue perfusion and
cerebral tissue swelling. which nursing intervention will be included in the plan of
care?
A. encourage coughing and deep breathing
B. position the patient with knees and hips flexed
C. keep the head of the bed elevated to 30 degrees
D. cluster nursing interventions to provide rest periods - (answer)C. keep the head
of the bed elevated to 30 degrees
Multiple sclerosis - (answer)a chronic, progressive degenerative disorder of the
CNS. Characterized by disseminated demyelination of nerve fibers in the brain
and spinal cord
myasthenia gravis - (answer)an autoimmune disease of the neuromuscular
junction. characterized by the fluctuating weakness of certain skeletal muscle
groups, which increases with muscle use.
,Guillain-Barre syndrome - (answer)autoimmune condition that causes acute
inflammation of the peripheral nerves in which myelin sheaths on the axons are
destroyed, resulting in decreased nerve impulses, loss of reflex response, and
sudden muscle weakness
Spinal cord injury - (answer)temporary or permanent alteration in the function of
the spinal cord, caused by trauma or damage to the spinal cord
Autonomic hyperreflexia (dysreflexia) - (answer)Massive, uncompensated
cardiovascular response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
- HTN, bradycardia, pounding headache
neurogenic shock - (answer)unopposed PSNS stimulation and disruption of SNS,
causing bradycardia, vasodilation, and hypotension.
usually occurs with SCI at T6 or above
spinal shock - (answer)spinal shock presents with total flaccid paralysis and loss of
all reflexes below the level of injury.
Intracranial pressure - (answer)the amount of pressure inside the skull controlled
by the three essential components of pressure in the skull: brain tissue, blood,
CSF
, A nurse is caring for a client who has a basilar skull fracture following a fall from a
ladder. Which of the following assessment findings should the nurse report to the
provider?
A. glasgow coma scale score of 15
B. intracranial pressure reading of 15mmHg
C. ecchymosis at base of skull
D. clear drainage from nose - (answer)D. clear drainage from nose
clear drainage indicates that CSF is leaking from the skill fracture
A nurse in an emergency department is caring for a client who suddenly lost
consciousness and fell in her home. the provider determines that the client had
an embolic stroke. Which of the following medications should the nurse
administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - (answer)A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
A nurse is assessing a client who had a right hemispheric stoke. Which of the
following neurologic deficits should the nurse expect?
ANSWERS LATEST UPDATE//ALREADY GRADED A+
the nurse advises a patient with myasthenia gravis to
A. perform physically demanding activities early in the day
B. anticipate the need for weekly plasmapheresis treatments
C. do frequent weight-bearing exercise to prevent muscle atrophy
D. protect the extremities from injury due to poor sensory perception -
(answer)A. perform physically demanding activities early in the day
To prevent autonomic hyperreflexia, which nursing action will the home health
nurse include in the plan of care for a patient who has paraplegia at the T4 level?
A. support selection of a high-protein diet
B. discuss options for sexuality and fertility
C. assist in planning a prescribed bowel program
D. use quad coughing to strengthen cough efforts - (answer)C. assist in planning a
prescribed bowel program
which assessment data for a patient who has Guillain-Barre syndrome will require
the nurses most immediate action?
A. the patients sacral area skin is reddened
B. the patient is continuously drooling saliva
C. the patient complains of severe pain in the feet
D. the patients blood pressure is 150/82 - (answer)B. the patient is continuously
drooling saliva
,The nurse has administered a prescribed IV osmotic diuretic to an unconscious
patient. which parameter should the nurse monitor to determine the medications
effectiveness?
A. blood pressure
B. intracranial pressure
C. oxygen saturation
D. hemoglobin and hematocrit - (answer)B. intracranial pressure
A patient who is unconscious has ineffective cerebral tissue perfusion and
cerebral tissue swelling. which nursing intervention will be included in the plan of
care?
A. encourage coughing and deep breathing
B. position the patient with knees and hips flexed
C. keep the head of the bed elevated to 30 degrees
D. cluster nursing interventions to provide rest periods - (answer)C. keep the head
of the bed elevated to 30 degrees
Multiple sclerosis - (answer)a chronic, progressive degenerative disorder of the
CNS. Characterized by disseminated demyelination of nerve fibers in the brain
and spinal cord
myasthenia gravis - (answer)an autoimmune disease of the neuromuscular
junction. characterized by the fluctuating weakness of certain skeletal muscle
groups, which increases with muscle use.
,Guillain-Barre syndrome - (answer)autoimmune condition that causes acute
inflammation of the peripheral nerves in which myelin sheaths on the axons are
destroyed, resulting in decreased nerve impulses, loss of reflex response, and
sudden muscle weakness
Spinal cord injury - (answer)temporary or permanent alteration in the function of
the spinal cord, caused by trauma or damage to the spinal cord
Autonomic hyperreflexia (dysreflexia) - (answer)Massive, uncompensated
cardiovascular response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
- HTN, bradycardia, pounding headache
neurogenic shock - (answer)unopposed PSNS stimulation and disruption of SNS,
causing bradycardia, vasodilation, and hypotension.
usually occurs with SCI at T6 or above
spinal shock - (answer)spinal shock presents with total flaccid paralysis and loss of
all reflexes below the level of injury.
Intracranial pressure - (answer)the amount of pressure inside the skull controlled
by the three essential components of pressure in the skull: brain tissue, blood,
CSF
, A nurse is caring for a client who has a basilar skull fracture following a fall from a
ladder. Which of the following assessment findings should the nurse report to the
provider?
A. glasgow coma scale score of 15
B. intracranial pressure reading of 15mmHg
C. ecchymosis at base of skull
D. clear drainage from nose - (answer)D. clear drainage from nose
clear drainage indicates that CSF is leaking from the skill fracture
A nurse in an emergency department is caring for a client who suddenly lost
consciousness and fell in her home. the provider determines that the client had
an embolic stroke. Which of the following medications should the nurse
administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - (answer)A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
A nurse is assessing a client who had a right hemispheric stoke. Which of the
following neurologic deficits should the nurse expect?
