NR-325 Adult Health II - Set 4 - Part 2

Correct Answer: Autonomic dysreflexia from a noxious stimulus

A systolic of 162 in a client whose baseline runs near ninety represents a dangerous rise, and the pounding headache with a slow pulse completes the classic dysreflexia picture. Option b is incorrect because neurogenic shock drives the pressure down, not up, and it belongs to the first hours after injury. Two months out, the sympathetic vascular tone below the lesion is back. Option c is incorrect because a client who is dropping pressure while upright feels faint and looks grey, with a low reading rather than a high one. The numbers here point the other way. Option d is incorrect because spinal shock is defined by absent reflexes and flaccid muscles in the days after trauma, and it carries no headache. Its resolution brings spasticity, not a hypertensive crisis.

Correct Answer: Relapses lasting days to weeks with recovery between

Relapsing remitting disease is the most common presenting course. Inflammatory plaques form in scattered central nervous system sites, cause deficits for days to weeks, then partly remyelinate so function returns between attacks. Option a is incorrect because steady decline without distinct attacks describes the primary progressive form. That variant affects a small minority and tends to begin later in life with heavy spinal cord involvement. Option c is incorrect because demyelination does not reverse in hours. Recovery from a relapse unfolds over weeks as oligodendrocytes repair myelin, and abrupt total paralysis suggests a vascular or spinal emergency instead. Option d is incorrect because plaques scatter through brain, brainstem, optic nerves and cord. Deficits therefore appear in unrelated places at unrelated times, which is precisely why the disease carries the word multiple.

Correct Answer: Dressing the upper body with adaptive aids

Wrist extension at the sixth cervical level gives a tenodesis grasp, so the client can manage upper body dressing, feeding and grooming with adaptive equipment. This is the major independence jump. Option b is incorrect because walking needs hip and knee power that lumbar segments supply, and none of those muscles are connected here. Community mobility for this client comes from a wheelchair. Option c is incorrect because the triceps are supplied by the seventh cervical root, one level lower than this injury. Without elbow extension the client cannot push the body up off the mattress. Option d is incorrect because the intercostal and abdominal muscles stay paralyzed at this level, leaving a weak breathy cough. Secretion clearance depends on an assisted cough delivered by the caregiver.

Correct Answer: "I do wall climbing with that arm above my shoulder now."

Overhead motion is withheld while drains and sutures remain, because full abduction pulls on the axillary incision and encourages seroma formation. Wall climbing belongs to the phase after the drains come out. Option a is incorrect because everyday self-care with the operative arm starts within the first postoperative days. Hair brushing and face washing keep the shoulder moving without stretching the suture line, so this statement is correct. Option c is incorrect because premedication is exactly what the nurse teaches. Unmanaged soreness is the usual reason clients skip their routine, and skipped sessions are what leave the shoulder frozen. Option d is incorrect because hand and wrist activity begins on the day of surgery. Squeezing a ball and pumping the hand push venous and lymphatic fluid upward without loading the healing axilla.

Correct Answer: "I will drink less so my bladder does not fill."

Fluid intake is timed rather than restricted. Cutting back concentrates the urine, which promotes stones and infection, and both of those become triggers for a hypertensive crisis in this client. Option a is incorrect because sticking to the schedule is exactly right, since a missed catheterization is the leading cause of a dysreflexia episode. That statement shows the teaching landed. Option b is incorrect because cloudy urine and new leakage are the symptoms worth reporting, and the client named them correctly. Culture results alone are not treated, but symptoms always deserve attention. Option c is incorrect because hand hygiene before every pass is the core of clean technique at home, and the client stated it plainly. Nothing in that sentence needs correcting before discharge.

Correct Answer: Stop the pulling and cue the client to march

Pulling a frozen client forward moves the trunk while the feet stay planted and topples them. Safety comes first, so the nurse stops the pull and gives a rhythmic cue such as marching in place. Option a is incorrect because a medication change does nothing for a client who is losing balance this second. Dose adjustment may follow later, but freezing responds poorly to drugs in any case. Option b is incorrect because retiring the client to a chair removes the mobility that preserves function. Walking with taught cues keeps muscles working, and blanket restriction accelerates deconditioning and contracture. Option d is incorrect because charting belongs after the immediate danger has passed. A client tipping forward with someone tugging an arm needs hands on protection, and the record can wait a few minutes.

Correct Answer: Heart rate dropping into the thirties during position changes

Autonomic instability makes profound bradycardia likely, and suctioning or vagal stimulation can drop the rate into asystole. The nurse holds suctioning, keeps atropine available and alerts the team before proceeding. Option a is incorrect because high protein with normal cells is albuminocytologic dissociation, the expected spinal fluid pattern. It confirms the diagnosis rather than signaling a change that demands bedside action. Option c is incorrect because severe back and limb pain is common and badly undertreated in this syndrome. It calls for prompt analgesia and repositioning, yet it does not threaten life the way an arrhythmia does. Option d is incorrect because loss of deep tendon reflexes defines the disorder from the start. Areflexia documents nerve root demyelination and is anticipated, so it prompts no urgent change in the plan.

Correct Answer: A tremor at rest that eases with purposeful reaching

Dopamine loss in the substantia nigra produces a resting pill rolling tremor that quiets when the hand is used and disappears in sleep. Rigidity, bradykinesia and postural instability complete the cardinal group. Option b is incorrect because a tremor that emerges during movement is an intention tremor. Cerebellar disease and multiple sclerosis produce that pattern, and it worsens as the hand nears its target. Option c is incorrect because tone rises rather than falls in this disorder. Cogwheel rigidity gives a ratchety catch on passive movement, and reflexes stay essentially normal because the motor neurons are intact. Option d is incorrect because dance like involuntary movement is chorea, the signature of Huntington disease. Parkinson disease produces too little movement, which is the opposite end of the basal ganglia spectrum.

Correct Answer: The injury is incomplete because sacral function persists

Any preserved function below the level, including perianal sensation or voluntary anal squeeze, makes the injury incomplete. Sacral sparing is the definitional pivot, and it predicts a better recovery. Option a is incorrect because complete means nothing survives below the lesion, including the lowest sacral segments. Perianal sensation on its own rules that label out no matter how paralyzed the legs look. Option b is incorrect because spinal shock wipes out every reflex and every sensation below the injury. A client who feels perianal touch and contracts the sphincter has already moved past that phase. Option d is incorrect because cauda equina damage sits below the first lumbar vertebra and brings severe radiating back pain with a flaccid, areflexic picture. A thoracic lesion cannot injure those roots.

Correct Answer: The sensory level has risen two segments

A sensory level climbing upward means cord edema is extending the injury toward the phrenic nerve roots. Respiratory failure follows, so this change is reported before anything else on the list. Option a is incorrect because a slow resting rate is expected once sympathetic input to the heart is cut off and vagal tone runs unopposed. It warrants monitoring rather than an urgent call. Option b is incorrect because paralytic ileus is nearly universal in the first two or three days, which is exactly why a nasogastric tube is already draining the stomach. Silent bowel sounds fit the expected course. Option c is incorrect because flaccid limbs with no reflexes describe spinal shock, the predictable early state after cord trauma. Reflexes return over days to weeks, and their absence now changes nothing about the plan.

Correct Answer: Intravenous gentamicin every eight hours for the infection

Aminoglycosides block acetylcholine release at the neuromuscular junction and can push a myasthenic client into respiratory failure. The nurse holds the drug and asks for an antibiotic that is safe in this disease. Option a is incorrect because acetaminophen has no effect on neuromuscular transmission. Lowering fever actually helps, since heat and infection are both recognized precipitants of myasthenic crisis in this population. Option b is incorrect because corticosteroids are standard immunotherapy for myasthenia gravis. Early transient worsening can occur, so the nurse watches strength closely, but the order itself is appropriate and expected. Option d is incorrect because a stool softener carries no neuromuscular risk. Constipation is common with limited mobility, and preventing straining is reasonable supportive care rather than a reason to call the provider.

Correct Answer: Tell the client to come in immediately

Fever with an absolute neutrophil count under five hundred is a medical emergency. The client needs blood cultures and broad spectrum antibiotics within the hour, so bringing the client in without delay drives everything else. Option b is incorrect because an antipyretic erases the single warning sign this client has. Masking the fever hides a spreading infection while bacteria multiply in a bloodstream with almost no defenders left. Option c is incorrect because overnight is long enough for gram negative bacteremia to progress to septic shock. Antibiotic delay in neutropenic sepsis raises mortality sharply, so morning is far too late. Option d is incorrect because hydration and rest treat a viral illness in a client with an intact immune system. Here the marrow is empty, and supportive advice alone leaves the infection untreated.

Correct Answer: Discuss starting noninvasive ventilation at night now

Morning headache and sleepiness with a falling vital capacity mean nocturnal hypoventilation. Noninvasive ventilation started before a crisis improves both survival and comfort, and breathing outranks every other problem on this list. Option a is incorrect because riluzole offers a modest survival gain at a fixed dose and does nothing for carbon dioxide retention overnight. Raising it would add liver risk without easing a single symptom described here. Option c is incorrect because a swallow study addresses aspiration, which matters but can wait days. Feeding tube placement is also safer before vital capacity drops, so this planning should already have happened. Option d is incorrect because attributing the headache to poor sleep misses the mechanism entirely. Carbon dioxide accumulating overnight is what wakes the client with a headache, and reassurance leaves that untreated.

Correct Answer: Grade describes cell appearance and stage describes spread

Grade comes from how closely the cells resemble the tissue they arose from, while stage maps the anatomic extent of disease. Stage carries the greater weight in planning treatment and predicting outcome. Option a is incorrect because stage does far more than direct the surgeon. It shapes the entire plan, including chemotherapy and radiation decisions, and it remains the strongest single predictor of prognosis. Option b is incorrect because size and nodal involvement both sit inside the staging system as the tumor and node components. Grading never measures dimensions; a pathologist judges differentiation under the microscope. Option c is incorrect because the stage assigned at diagnosis stays with the client even when disease later recurs at a distant site. Recurrence is described against the original stage rather than renumbered.

Correct Answer: The nodule suggests cancer; the smooth gland suggests hyperplasia

Cancer arises in the peripheral zone and feels hard, irregular, and asymmetric, and bone pain reflects spread. Hyperplasia grows in the transition zone around the urethra, feels smooth and rubbery, and obstructs early. Option b is incorrect because a discrete hard nodule does not belong to benign growth. Hyperplasia enlarges the gland evenly, so an asymmetric lump is the exact finding that sends a man to biopsy. Option c is incorrect because the antigen level is not specific for malignancy. Gland size, prostatitis, urinary infection, recent ejaculation, cycling, and even a rectal examination all push the value upward. Option d is incorrect because it reverses both descriptions. Smooth symmetrical enlargement is the benign picture, and an infected prostate is boggy and exquisitely tender rather than firm and nodular.

Correct Answer: Assess the catheter and drain the bladder

Bladder distension causes roughly eighty five percent of episodes, so the drainage system is checked and the bladder emptied next. Relieving that stimulus usually ends the sympathetic surge on its own. Option a is incorrect because pressing on the abdomen is itself a noxious stimulus below the lesion and drives the pressure higher. The Crede maneuver has no place in the management of this emergency. Option c is incorrect because the rectum is examined only after the bladder has been cleared, and never without anesthetic jelly instilled first. Digital stimulation adds another trigger while the pressure is still climbing. Option d is incorrect because a cool cloth treats the headache as a comfort problem when the headache is a symptom of stroke level hypertension. Comfort measures leave the underlying stimulus untouched.

Correct Answer: Raise the head of the bed fully

Sitting the client fully upright pools blood in the abdomen and legs, dropping the pressure within seconds. Gravity is the fastest tool available, so it comes before any search for the trigger. Option a is incorrect because tracing the drainage system is the correct second move, not the opening one. Positioning takes seconds and starts working immediately, while unkinking tubing does nothing about the pressure already in the skull. Option b is incorrect because drugs are held until the client is upright and the bladder has been addressed. Relieving the stimulus drops pressure on its own, and an early dose invites rebound hypotension. Option d is incorrect because calling for help while the client lies flat wastes the one intervention the nurse can deliver instantly. The provider is notified, but only after positioning and bladder relief are under way.

Correct Answer: Worsening back pain that is worse lying flat

New back pain that intensifies when the client lies down is the earliest sign of spinal cord compression, and it arrives days to weeks before weakness. Function preserved at treatment predicts function afterward. Option a is incorrect because mild nausea on day two is an expected effect handled with the antiemetics already prescribed. The nurse reviews the schedule and follows up, but no emergency exists. Option b is incorrect because altered taste is a common and reversible nuisance during chemotherapy. Cold protein sources and plastic utensils usually help, and nothing about dysgeusia threatens organ function or safety. Option c is incorrect because hair loss beginning a week or two into therapy follows the expected course. It distresses clients deeply and deserves attention at the next visit, though it is not a physical emergency.

Correct Answer: A new headache with confusion and slurred speech

Headache paired with a change in mental status points to intracranial bleeding, the complication that kills fastest in severe thrombocytopenia. Neurologic change outranks visible bleeding elsewhere and demands an immediate call. Option a is incorrect because petechiae are the expected surface marker of a low platelet count. They are documented and monitored, though pinpoint spots alone carry none of the urgency of bleeding inside the skull. Option b is incorrect because hematuria does warrant reporting and continued watching. Blood loss through the urinary tract, however, unfolds slowly enough to allow assessment, unlike a neurologic change unfolding at the bedside. Option d is incorrect because oozing gums are common once platelets fall this far. Pressure, a switch to swabs alone, and reporting at the next contact handle it, since the airway and brain are not threatened.

Correct Answer: A distended bladder from a blocked catheter

Roughly eighty five percent of episodes come from the bladder, and a blocked catheter is the classic culprit at home. The nurse traces the tubing before looking anywhere else. Option b is incorrect because skin lesions sit third on the list of triggers and are searched only once bladder and bowel have been cleared. A heel ulcer can provoke an episode but rarely explains one. Option c is incorrect because impaction ranks second, not first, so it moves to the front of the search only after the drainage system has been checked and the bladder emptied. Option d is incorrect because a toenail qualifies as a noxious stimulus yet accounts for a small fraction of cases. Checking a toe while urine backs up wastes minutes the client does not have.