You are assessing a spinal trauma patient who is complaining of pain at T1. where would you expect to see a change in response as you assess the patient to determine if there is cord involvement at this level?
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You are assessing a spinal trauma patient who is complaining of pain at T1. where would you expect to see a change in response as you assess the patient to determine if there is cord involvement at this level? A) at the nipple line. B) at the 2nd Intercostal space. C) at the index finger and sternal notch. D) at the little finger and 2nd intercostal space.
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- A 70-year-old male is scheduled for surgery. He says to thenurse, “I am so frightened—what if I don’t wake up?” Whatwould be the nurse’s best response?a. “You have a wonderful doctor.”b. “Let’s talk about how you are feeling.”c. “Everyone wakes up from surgery!”d. “Don’t worry, you will be just fine.”An older adult has been given a benzodiazepine for sleep induction, but the night nurse noted that the patient was awake most of the night, watching television and reading in bed. The nurse documents that the patient has had which type of reaction to the medication?a) Allergicb) Teratogenicc )Paradoxicald )IdiopathicMatch the correct terms with their meanings. Place the correct letter in the empty column Term Letter Definition a) closer to the top of the limb b) lying face downwards c) towards the head, or above d) back or at the back of e) closer toward the bottom or end of a Superior Inferior Anterior Posterior Lateral limb Medial f) towards the feet or below Proximal g) front, or in front of h) lying face upwards i) toward the side of the body, or away Distal Supine from the midline of the body Prone j) toward the midline of the body Choose/circle the correct answer. Assume the individual is in anatomical position. 1. The big toe is on the lateral/medial side of the foot. 2. The shoulder blade is on the anterior/posterior side of the body. 3. The hand is distal/proximal to the elbow. 4. The hips are superior/inferior to the shoulders. 5. The shoulders are medial/lateral to the spine. 6. The knee is distal/proximal to the ankle. 7. The knee is superior/inferior to the ankle.
- The nurse is administering an NMBD to a patient during a surgical procedure. Number the following phases of muscle paralysis in the order in which the patient will experience them. (Number 1 is the first step.)a )Paralysis of intercostals and diaphragm musclesb) Muscle weaknessc) Paralysis of muscles of the limbs, neck, and trunkd )Paralysis of small rapidly moving muscles (fingers, eye)A 45-year-old man undergoes repair of a symptomatic inquinal hernia. Durina the operation. the hernia is reduced through its origin. This patient has an indirect inquinal hernia if it is located lateral to which of the following anatomic landmarks?A) Inferior epigastric arteryB) Inguinal ligamentC) Rectus abdominis muscleD) Superior epigastric veinE) Symphysis pubisWhen performing a neurological assessment on a patient with a suspected stroke, the nurse assesses for: A) Bradycardia B) Hypertonicity C) Increased bowel sounds D) Contralateral weakness or paralysis
- A nurse instructor is teaching a class of student nurses aboutthe nature of pain. Which statements accurately describe thisphenomenon? Select all that apply.a. Pain is whatever the physician treating the pain says it is.b. Pain exists whenever the person experiencing it says itexists.c. Pain is an emotional and sensory reaction to tissue damage. d. Pain is a simple, universal, and easy-to-describephenomenon.e. Pain that occurs without a known cause is psychological innature. f. Pain is classified by duration, location, source, transmis-sion, and etiology.21) the term encephalomalacia means hardening of the brain A) true B) FalseConditions resulting in the total or partial absence of a corpus callosum in childhood a) are lethal. b) show "disconnection syndrome." c) only happen before birth. d) may be asymptomatic.
- What consideration should the nurse keep in mind regardingthe use of side rails for a confused patient?a. They prevent confused patients from wandering.b. A history of a previous fall from a bed with raised siderails is insignificant.c. Alternative measures are ineffective to prevent wandering.d. A person of small stature is at increased risk for injuryfrom entrapment.A patient is about to undergo cardioversion, and the nurse is reviewing the procedure and explaining moderate sedation. The patient asks, “I am afraid of feeling it when they shock me?” What is the nurse’s best response? a) “You won’t receive enough of a shock to feel anything.” b) “You will feel the shock but you won’t remember any of the pain.” c )“The medications you receive will reduce any pain and help you not to remember the procedure.” d )“They will give you enough pain medication to prevent you from feeling it.”What is the primary purpose of the Glasgow Coma Scale (GCS) in nursing assessment? a) Assessing pain levels b) Measuring blood pressure c) Evaluating neurological status d) Monitoring respiratory rate