NEURO FINAL EXAM - 19. A client is admitted with a cervical...

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19. A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Dressing or grooming self-care deficit Correct Answer: B RATIONALES: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern. The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it: A. dilates cerebral blood vessels. B. constricts cerebral blood vessels. C. decreases peripheral vascular resistance. D. decreases the stimulation of baroreceptors. Correct Answer: B RATIONALES: Ergotamine relieves migraine headaches by constricting cerebral arterial vessels. The drug's ability to prevent norepinephrine reuptake may add to this effect. The net result is decreased pulsatile blood flow through the cerebral vessels and symptom relief. Ergotamine doesn't decrease either peripheral vascular resistance or stimulation of baroreceptors. The nurse is administering neostigmine to a client with myasthenia gravis . Which nursing intervention should the nurse implement? A. Give the medication on an empty stomach. B. Warn the client that he'll experience mouth dryness. C. Schedule the medication before meals. D. Administer the medication for complaints of muscle weakness or difficulty swallowing. Correct Answer: C RATIONALES: Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia , sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels.
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A client is color blind. The nurse understands that this client has a problem with: A. rods. B. cones. C. lens. D. aqueous humor. Correct Answer: B RATIONALES: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid that isn't involved with color perception. 20. A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse
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This note was uploaded on 03/11/2012 for the course MED 101 taught by Professor Nok during the Spring '12 term at Amity University.

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NEURO FINAL EXAM - 19. A client is admitted with a cervical...

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