A client has a cervical spine injury at the level of C5. What would you expect during the acute phase?

The need for mechanical ventilation

The nurse assists the client into which of the following positions for a lumbar puncture?

Side-lying, with the legs pulled up and the head bent down onto the chest.

A client with quadriplegia is flushed, with a blood pressure of 210/100 and a HR of 50 bpm. What should be done first?

Raise the HOB immediately to 90 degrees

A 40-year-old paraplegic must perform intermittent catheterization of the bladder. What are appropriate instructions?

“Clean the meatus with soap and water.”

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NEURO pt 2

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Answers

1
A client has a cervical spine injury at the level of C5. What would you expect during the acute phase?
Absent corneal reflex
Decerebrate posturing
The need for mechanical ventilation
Movement of only the right or left half of the body
2
Which standardized tool is a guide in assessing a client with a head injury and increased intracranial pressure (ICP)?
Pulse oximetry graph
Visual analogue scale
Snellen chart
Glasgow coma scale
3
The nurse is discussing the purpose of an electroencephalogram (EEG). What does an EEG tell you?
Extent of intracranial bleeding
Sites of brain injury
Percent of functional brain tissue
Activity of the brain
4
The nurse assists the client into which of the following positions for a lumbar puncture?
Side-lying, with the legs pulled up and the head bent down onto the chest.
Prone, in slight Trendelenburg's position
Prone, with a pillow under the abdomen
Side-lying, with a pillow under the hip
5
Which assessment would take priority for a patient with a C5 fracture?
The client's feeling about the injury
Bladder distention
Neurological deficit
Pulse ox readings
6
A client with quadriplegia is flushed, with a blood pressure of 210/100 and a HR of 50 bpm. What should be done first?
Give one SL nitroglycerin tablet
Place the client flat in bed
Raise the HOB immediately to 90 degrees
Assess patency of the indwelling catheter
7
A client with multiple sclerosis is experiencing muscle weakness, spasticity and an ataxic gait. Nursing diagnoses is?
Self care deficit
Impaired physical mobility
Impaired tissue integrity
Risk for activity intolerance
8
Which position will increase ICP?
Supine
90 degrees
Semi Fowlers
High Fowlers
9
The nurse is assessing the motor function of an unconscious client. What test is used to assess peripheral pain response
Squeezing the sternocleidomastoid muscle
Nail bed pressure
Pressure on the orbital rim
Sternal rub
10
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. What are appropriate instructions?
“Measure the quantity of urine.”
“Gently rotate the catheter during removal.”
“Clean the meatus from back to front.”
“Clean the meatus with soap and water.”

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