adult health 2 hesi
A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic
lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for
further teaching about the disease?
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
D. "I understand that I'm going to be vulnerable to getting infections." - (correct Answer) - c. SLE carries
an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
Midazolam (Versed) has been ordered for a patient to be administered by injection 30 minutes prior to a
colonoscopy. The nurse informs the patient that one of the most common side effects of this medication
is which effect?
A. Decreased heart rate
B. Amnesia
C. Constipation
D. Dry mouth - (correct Answer) - b. Versed is known to cause amnesia and anxiolysis as well as sedation
and is therefore commonly used prior to certain procedures.
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident.
The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The
nurse recognizes this condition as which of the following?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome - (correct Answer) - b. About 50% of people with acute spinal cord injury
experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock.
Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the
lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-
, Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory
function.
Which of the following clinical manifestations would the nurse interpret as representing neurogenic
shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - (correct Answer) - a. Neurogenic shock is due to the loss of vasomotor tone
caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation
causes peripheral vasodilation, venous pooling, and a decreased cardiac output.
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the
following assessment findings would alert the nurse to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache - (correct Answer) - d. Autonomic dysreflexia is related to reflex stimulation of
the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and
diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest
priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical spinal cord injury - (correct Answer) - d.
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture.
Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory
needs are always the highest priority. Remember the ABCs.
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which
of the following assessments should the nurse prioritize?
A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic
lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for
further teaching about the disease?
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
D. "I understand that I'm going to be vulnerable to getting infections." - (correct Answer) - c. SLE carries
an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
Midazolam (Versed) has been ordered for a patient to be administered by injection 30 minutes prior to a
colonoscopy. The nurse informs the patient that one of the most common side effects of this medication
is which effect?
A. Decreased heart rate
B. Amnesia
C. Constipation
D. Dry mouth - (correct Answer) - b. Versed is known to cause amnesia and anxiolysis as well as sedation
and is therefore commonly used prior to certain procedures.
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident.
The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The
nurse recognizes this condition as which of the following?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome - (correct Answer) - b. About 50% of people with acute spinal cord injury
experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock.
Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the
lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-
, Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory
function.
Which of the following clinical manifestations would the nurse interpret as representing neurogenic
shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - (correct Answer) - a. Neurogenic shock is due to the loss of vasomotor tone
caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation
causes peripheral vasodilation, venous pooling, and a decreased cardiac output.
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the
following assessment findings would alert the nurse to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache - (correct Answer) - d. Autonomic dysreflexia is related to reflex stimulation of
the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and
diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest
priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical spinal cord injury - (correct Answer) - d.
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture.
Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory
needs are always the highest priority. Remember the ABCs.
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which
of the following assessments should the nurse prioritize?
