To evaluate the effectiveness of mannitol, the nurse should monitor:

Sodium level.

Fluid intake.

Heart rate.

Urine output.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Monitoring sodium levels is important when administering mannitol, but it is not the primary indicator of the drug's effectiveness. Mannitol is an osmotic diuretic used to reduce intracranial pressure, and its effectiveness is better assessed by other means.

Choice B reason:

Fluid intake is important to monitor to ensure proper hydration status, but it does not directly indicate the effectiveness of mannitol. The primary focus should be on the patient's output to assess the diuretic effect.

Choice C reason:

Heart rate monitoring is essential for overall patient care but does not directly indicate the effectiveness of mannitol. Changes in heart rate can occur due to various factors and are not specific to mannitol's action.

Choice D reason:

Urine output is the most direct measure of mannitol's effectiveness. As an osmotic diuretic, mannitol promotes diuresis, and increased urine output indicates that the drug is effectively reducing intracranial pressure.

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Correct Answer is B

Explanation

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

A. Flaccid paralysis and lack of sensation below the level of the injury B. Hypotension, bradycardia, and warm extremities C. Presence of hyperactive reflex activity below the level of the injury D. Severe headache, hypertension, and flushed face

Correct Answer is A

Explanation

Choice A reason:

Flaccid paralysis and lack of sensation below the level of the injury are classic signs of spinal shock. Spinal shock is characterized by a temporary loss of all reflexes, motor, and sensory activity below the level of injury, which typically occurs immediately following the injury. Recognizing these signs is crucial for the timely management of the condition.

Choice B reason:

Hypotension, bradycardia, and warm extremities are more indicative of neurogenic shock rather than spinal shock. Neurogenic shock results from the loss of sympathetic tone following a spinal cord injury, leading to cardiovascular changes. These signs do not specifically indicate spinal shock.

Choice C reason:

The presence of hyperactive reflex activity below the level of the injury is not associated with spinal shock. Spinal shock involves the loss of reflex activity rather than hyperactivity. Hyperactive reflexes might develop later as the spinal cord recovers from the initial shock phase.

Choice D reason:

Severe headache, hypertension, and flushed face are symptoms more commonly associated with autonomic dysreflexia, not spinal shock. Autonomic dysreflexia occurs in patients with spinal cord injuries at or above the T6 level and is a response to a noxious stimulus below the level of injury. These symptoms are not indicative of spinal shock.

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To evaluate the effectiveness of mannitol, the nurse should monitor:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

Correct Answer is B

Explanation

A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

Correct Answer is A

Explanation

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

Which would be the most important action immediately following extubation of a patient?

Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

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