Question

A nurse Is caring for a client who has spinal stenosis. Which of the following conditions should the nurse recognize as a risk factor for spinal stenosis?

Answer 1

Correct Answers:

Laminectomy

Rationale :

🔷 Definition: A laminectomy is a surgical procedure where part of the vertebral bone is removed to relieve spinal cord pressure.

🔷 Risk factor: This procedure can later cause instability, scar tissue, or narrowing of the spinal canal, leading to spinal stenosis.

🔷 Other options: Hyperthyroidism, hysterectomy, and COPD are not related to spinal stenosis development.

🔷 Nursing implication: Monitor clients with past laminectomy for chronic back pain, weakness, or numbness.

🔷 Long-term risk: Degenerative changes after laminectomy may accelerate spinal narrowing.

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Answer 2

Correct Answers:

"If you have an erection for more than four hours, seek emergency treatment.

Rationale :

💠 Priority teaching: The highest priority is priapism, a prolonged erection that can cause permanent tissue damage if untreated.

💠 Safety risk: This is a medical emergency, requiring immediate attention.

💠 Other teaching points: While prevention of STIs, timing, and headaches are important, life-threatening risks take priority.

💠 Nursing role: Stress the need for immediate ER visit if priapism occurs.

💠 Patient safety: Prevents complications such as ischemia, necrosis, and erectile dysfunction.

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Answer 3

Correct Answers:

"The elevated blood sugar from my diabetes can cause underlying nerve damage."

Rationale :

⭐ Pathophysiology: Chronic hyperglycemia damages blood vessels supplying nerves, leading to peripheral neuropathy.

⭐ Symptoms: Numbness, tingling, and burning pain in extremities, especially feet.

⭐ Other options: Aging, random unknown reasons, or “nerves going to sleep” are incorrect explanations.

⭐ Nursing education: Emphasize glycemic control to reduce progression.

⭐ Complication prevention: Helps lower risk of foot ulcers, infection, and amputations.

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Answer 4

Correct Answers:

Falls

Rationale :

🔵 Older adults: In people over 65 years, the leading cause of spinal cord injuries is falls, due to osteoporosis, balance issues, and frailty.

🔵 Other causes: Motor vehicle accidents are common in younger adults, while sports and gunshot wounds are less frequent in the elderly.

🔵 Prevention: Safety measures like mobility aids, home hazard removal, and exercise can reduce fall risk.

🔵 Nursing implication: Focus education on fall prevention strategies in older adults.

🔵 Statistics: Falls account for over 60% of spinal cord injuries in elderly populations

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Answer 5

Correct Answers:

The client's history of stroke, because stroke can lead to dementia due to changes in the blood vessels of the brain.

Rationale :

🔷 Pathophysiology: Vascular dementia occurs when impaired blood flow (from strokes or vascular disease) damages brain tissue.

🔷 Risk factors: Stroke and hyperlipidemia increase risk, but stroke history is the most direct link.

🔷 Incorrect options: Peptic ulcer disease does not cause dementia.

🔷 Clinical presentation: Progressive memory loss, forgetfulness, and cognitive decline following stroke.

🔷 Nursing role: Provide support for memory care, stroke prevention, and caregiver education.

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Answer 6

Correct Answers:

Muscle strength
Facial symmetry
Vision changes
Aphasia

Rationale :

🔷 Stroke suspicion: A client who collapses suddenly may be experiencing a cerebrovascular accident (CVA).

🔷 Muscle strength: Assess for unilateral weakness or paralysis.

🔷 Facial symmetry: Drooping is a key FAST (Face, Arm, Speech, Time) sign of stroke.

🔷 Vision changes: Sudden vision loss or double vision suggests neurological involvement.

🔷 Aphasia: Assess speech for slurring or difficulty forming words.

🔷 Peripheral pulses and smoking history are important later, but not immediate stroke assessments.

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Answer 7

Correct Answers:

Pupillary dilation
Persistent headache
Difficulty waking

Rationale :

💠 Head injury concern: A loss of consciousness followed by orientation suggests possible concussion or intracranial bleed.

💠 Pupillary dilation: Unequal or dilated pupils = rising intracranial pressure (ICP).

💠 Persistent headache: A red flag for intracranial bleeding.

💠 Difficulty waking: Indicates worsening neurological decline.

💠 Hand tremors and foot drop are not classic acute head injury findings.

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Answer 8

Correct Answers:

Inform the client about the need to move prior to the actual event.

Rationale :

⭐ Alzheimer’s & transition: Clients with dementia benefit from preparation and orientation before a move.

⭐ Relocation stress syndrome: Advanced notice reduces anxiety and confusion.

⭐ Incorrect options: Leaving client alone, limiting team members, or focusing on education/goals do not address stress reduction.

⭐ Nursing goal: Provide reassurance, consistency, and preparation.

⭐ Outcome: Smooth transition to facility with reduced agitation.

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Answer 9

Correct Answers:

Numbness and tingling in the hands and feet

Rationale :

🔵 Peripheral neuropathy hallmark: Damage to peripheral nerves causes paresthesias in extremities.

🔵 Cause: Often linked to diabetes mellitus, vitamin deficiencies, or toxins.

🔵 Other symptoms: Burning pain, loss of sensation, or weakness in affected areas.

🔵 Incorrect options: Blurred vision (retinopathy), chest pain (cardiac), and difficulty swallowing (cranial nerve/neurological disease) are not typical.

🔵 Nursing role: Teach foot care, glycemic control, and injury prevention

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Answer 10

Correct Answers:

Weight loss
Decreased mobility
Unkempt appearance
Constipation

Rationale :

💠 Weight loss: Dementia often leads to forgetting to eat or difficulty swallowing.

💠 Decreased mobility: Progressive decline in motor skills and independence.

💠 Unkempt appearance: Clients may forget to bathe or groom, requiring caregiver support.

💠 Constipation: Reduced dietary intake, immobility, and medications contribute to bowel changes.

💠 Not expected: Increased physical activity—dementia reduces, not increases, activity.

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NUR 420 ADULT MS NURSING 11 TEST

No.

1 :
A nurse Is caring for a client who has spinal stenosis. Which of the following conditions should the nurse recognize as a risk factor for spinal stenosis?

2 :
A nurse is providing medication teaching about sildenafil to a client who has erectile dysfunction. Which of the following statements is the nurse's highest priority?

4 :
A nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

6 :
A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete? (Select All that Apply.)

7 :
A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?(Select All that Apply.

8 :
A nurse is caring for a client who has Alzheimer's disease and is going to transition from home to a skilled nursing facility. Which of the following interventions should the nurse incorporate into the plan of care to help the client with this transition and avoid relocation stress syndrome?

9 :
Which of the following is a common symptom of peripheral neuropathy?

10 :
A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor? (Select All that Apply.)

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NUR 420 ADULT MS NURSING 11 TEST

No.

1 : A nurse Is caring for a client who has spinal stenosis. Which of the following conditions should the nurse recognize as a risk factor for spinal stenosis?

2 : A nurse is providing medication teaching about sildenafil to a client who has erectile dysfunction. Which of the following statements is the nurse's highest priority?

4 : A nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

6 : A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete? (Select All that Apply.)

7 : A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?(Select All that Apply.

8 : A nurse is caring for a client who has Alzheimer's disease and is going to transition from home to a skilled nursing facility. Which of the following interventions should the nurse incorporate into the plan of care to help the client with this transition and avoid relocation stress syndrome?

9 : Which of the following is a common symptom of peripheral neuropathy?

10 : A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor? (Select All that Apply.)

1 :
A nurse Is caring for a client who has spinal stenosis. Which of the following conditions should the nurse recognize as a risk factor for spinal stenosis?

2 :
A nurse is providing medication teaching about sildenafil to a client who has erectile dysfunction. Which of the following statements is the nurse's highest priority?

4 :
A nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

6 :
A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete? (Select All that Apply.)

7 :
A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?(Select All that Apply.

8 :
A nurse is caring for a client who has Alzheimer's disease and is going to transition from home to a skilled nursing facility. Which of the following interventions should the nurse incorporate into the plan of care to help the client with this transition and avoid relocation stress syndrome?

9 :
Which of the following is a common symptom of peripheral neuropathy?

10 :
A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor? (Select All that Apply.)