A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action would the nurse take first?

Give the prescribed antiemetic.

Check for a fecal impaction.

Assess the blood pressure (BP).

Notify the health care provider.

Answer and Explanation

The Correct Answer is C

Choice A reason: Giving an antiemetic treats nausea but doesn’t address the headache and nausea’s cause, likely autonomic dysreflexia in T3 injury. Assessing blood pressure identifies this emergency, making this secondary and incorrect compared to the nurse’s priority of evaluating the patient’s urgent symptoms.

Choice B reason: Checking for fecal impaction is relevant for autonomic dysreflexia but secondary to blood pressure assessment, which confirms the emergency. Immediate BP evaluation is critical, making this delayed and incorrect compared to the nurse’s first action for the patient’s symptoms.

Choice C reason: Assessing blood pressure first is critical, as headache and nausea in a T3 spinal cord injury patient suggest autonomic dysreflexia, a hypertensive emergency. This aligns with neurological nursing priorities, making it the correct initial action to address the patient’s urgent symptoms.

Choice D reason: Notifying the provider is important but follows assessing blood pressure to confirm autonomic dysreflexia. Immediate BP evaluation guides care, making this premature and incorrect compared to the nurse’s first action to evaluate the T3 injury patient’s headache and nausea.

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Correct Answer is ["A","B","D"]

Explanation

Choice A reason: A suction setup is essential for airway clearance in medical patients with respiratory or neurological issues. This aligns with medical nursing unit preparedness, making it a correct piece of equipment the nurse should have available for the transferred patient’s care needs.

Choice B reason: An oxygen tank is critical for patients with respiratory distress or hypoxia, common in medical unit admissions. This aligns with standard medical nursing equipment, making it a correct item the nurse should ensure is available for the emergency department transfer patient.

Choice C reason: A urinary catheter may be needed for specific conditions but isn’t universally required for medical unit transfers. Suction and oxygen are more broadly applicable, making this incorrect, as it’s not a standard immediate need for all transferred patients.

Choice D reason: Side rail pads prevent injury in patients with seizures or agitation, common in medical units. This aligns with patient safety protocols, making it a correct piece of equipment the nurse should have available for the patient transferred from the emergency department.

Choice E reason: A tongue blade is used for oral exams but isn’t critical for immediate medical unit needs. Suction and oxygen address urgent issues, making this incorrect, as it’s not a priority equipment item for the transferred patient’s care requirements.

Choice F reason: A nasogastric tube is specific to gastrointestinal issues, not a universal need for medical unit transfers. Side rail pads are more broadly applicable, making this incorrect, as it’s not a standard immediate equipment need for the transferred patient.

A. Metoprolol 50 mg. B. Carbidopa-Levodopa 25/100 mg. C. Benztropine (Cogentin). D. Aspirin 81 mg daily. E. Lisinopril 20 mg. F. Atorvastatin 20 mg.

Correct Answer is ["B","C"]

Explanation

Choice A reason: Metoprolol treats hypertension and heart conditions, not Parkinson’s symptoms like tremors or stiffness. Carbidopa-levodopa addresses these directly, making this incorrect, as it is not used for Parkinson’s management in the patient’s medication regimen for neurological symptoms.

Choice B reason: Carbidopa-levodopa is a primary Parkinson’s treatment, increasing dopamine to reduce tremors and stiffness. This aligns with neurological pharmacotherapy, making it a correct medication the nurse would recognize as typically used for Mr. Frank’s Parkinson’s disease management.

Choice C reason: Benztropine (cogentin) is an anticholinergic used in Parkinson’s to reduce tremors and rigidity. This aligns with standard Parkinson’s treatment protocols, making it a correct medication the nurse would identify as part of Mr. Frank’s regimen for managing his neurological symptoms.

Choice D reason: Aspirin is used for cardiovascular protection, not Parkinson’s symptoms like muscle stiffness. Carbidopa-levodopa is specific to Parkinson’s, making this incorrect, as it does not address the neurological symptoms of Mr. Frank’s diagnosed condition in his treatment plan.

Choice E reason: Lisinopril manages hypertension, not Parkinson’s-related tremors or walking difficulties. Benztropine targets these symptoms, making this incorrect, as it is irrelevant to the neurological management of Mr. Frank’s Parkinson’s disease in his home medication list.

Choice F reason: Atorvastatin treats hyperlipidemia, not Parkinson’s symptoms like stiffness or tremors. Carbidopa-levodopa is a Parkinson’s treatment, making this incorrect, as it does not contribute to managing Mr. Frank’s neurological condition in his prescribed medication regimen.

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A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action would the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient from the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

Mr. Frank, a 67-year-old male, is admitted to the neurology unit with difficulty walking, tremors, and muscle stiffness. He has Parkinson’s disease diagnosed 6 years ago. Which of Mr. Frank’s home medications is typically used to treat Parkinson’s? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

Which effect on the central nervous system is related to symptoms of multiple sclerosis (MS)?

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Which condition would the nurse suspect in a patient recovering from the removal of a brain tumor with an increase in urinary output to 450 ml of very light urine in the past hour?

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action would the nurse take first?