Detailed Answer Key

Neuro-Shock & Burns practice/ATI detailed answer key

Created on:11/26/2018 Page 1

1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspectedcervical

cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.)

A. Hypotension

B. Polyuria

C. Hyperthermia

D. Absence of bowel sounds

E. Weakened gag reflex

Rationale: <b>Hypotension is correct.</b> Lack of sympathetic input can cause a decrease in blood pressure. The

nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal

cord.</br></br><b>Polyuria is incorrect.</b> The nurse should check the client for bladder distention and

inability to urinate due to ineffective function of the bladder muscles.</br></br><b>Hyperthermia is

incorrect.</b> The nurse should monitor the client for hypothermia caused by a lack of lack of

sympathetic input.</br></br><b>Absence of bowel sounds is correct.</b> Spinal shock leads to

decreased peristalsis, which could cause the client to develop a paralytic ileus.</br></br><b>Weakened

gag reflex is correct.</b> The nurse shouldmonitor the client for difficulty swallowing, or coughing and

drooling noted with oral intake.

2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Whichof the

following statements by the client indicates a need for further teaching?

A. "I will notify my doctor before taking any other medications."

Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should benotified

that the client is taking phenytoin.

B. "I have made an appointment to see my dentist next week."

Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dentalmonitoring


C. "I know that I cannot switch brands of this medication."

Rationale:The client understands that bioavailability varies with different brands, so no substitutions shouldbe made.

D. "I'll be glad when I can stop taking this medicine."

Rationale:Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsantmedications

commonly require them for lifetime administration, and phenytoin should not be stopped without the

advice of the client's provider.

3. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new

Detailed Answer Key

Neuro-Shock & Burns practice

Created on:11/26/2018 Page 2

prescription for timolol eye drops. Which of the following instructions should the nurse provide?

A. The medication is to be applied when the client is experiencing eye pain.

Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserveremaining


B. The medication will be used until the client's intraocular pressure returns to normal.

Rationale:Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen theclient's


C. The medication should be applied on a regular schedule for the rest of the client's life.

Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, ordecrease its

production, or both. The client must continue the eye drops on an uninterrupted basis for life to

maintain intraocular pressure at an acceptable level.

D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.

Rationale:Treatment for open-angle glaucoma is to continue for life

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