neurogenic shock nclex questions

3. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. Nursing resources for students and nurses. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. Option B: Vasopressor medications are administered per protocol. 3. NCLEX Exam: Neurological Disorders 2 – Seizures (Sections 1) * An 18-year-old client is admitted with a closed head injury sustained in a MVA. Neurogenic shock Feedback. The nurse takes quick action, knowing this is compatible with: The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. Hyperreflexia This is a 50-item NCLEX style examination all about diseases affecting the Neurological System. Venous bleeding from the arachnoid space. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Answer: 1. HIV, AIDS, Cancer And Immune NCLEX . It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Which of the following assessments would take priority? If you leave this page, your progress will be lost. However, because it’s compatible with normal saline solution, it can be injected through an IV line containing normal saline. 4. Which of the following statements best described a lucid interval? Tachycardia The nurse suspects which of the following conditions? The catheter doesn’t need to be rotated during removal. Option C: Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. Administer 100 mg of pentobarbital IV as ordered. Answer: 3. This may resolve in time. :). Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. 3. Refer patients with an increased heart becomes unable to support the nurse that mr. Students in patients with an ancc exam score. Teach patient about the need for good oral hygiene. Provide emollients to the skin to prevent breakdown Intermittent catheterization should begin every 2 to 4 hours early in the treatment. 4. Neurogenic shock NCLEX questions for nursing students! Open the airway with the head-tilt-chin-lift maneuver. A CT scan of the head shows a collection of blood between the skull and dura mater. Article by Nursing KAMP. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. This type of shock is caused by a loss of communication between the sympathetic nervous system and the blood vessels it controls. Epidural hematoma. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Methylprednisolone (Solu-Medrol). Options B, C, and D: Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia. Check all that apply. Call the physician to adjust the ventilator settings. 2. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score. 37. A client has a cervical spine injury at the level of C5. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. I failed my first test and in an awesome feat of panic managed to score really high one the following tests allowing me to pass my MedSurg class. D. 2. Moving the client quickly as one unit. Which of the following nursing interventions should be done first? 2. Answer: 2. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. A client is admitted with a spinal cord injury at the level of T12. Types of distributive shock include septic, neurogenic, and anaphylactic shock. 22. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Neurogenic shock occurs when the nervous system loses it ability to stimulate nerves that regulate the size of the vessels. Neurogenic Shock NCLEX Questions 1. Guaiac-positive stools Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the anti-diuretic hormone. Option B: Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. 1. Laceration of the middle meningeal artery. 4. Option A: Autonomic dysreflexia occurs after neurogenic shock abates. Description. An interval when the client is alert but can’t recall recent events Activity of the brain 4. Insert an indwelling urinary catheter to straight drainage, Schedule intermittent catheterization every 2 to 4 hours, Perform a straight catheterization every 8 hours while awake. 10 Shock NCLEX® Questions Take the Pop Quiz and see how good you are at Shock NCLEX® Questions. Septic Shock NCLEX Review, Lecture on Cardiogenic Shock Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Nasal flaring. Neurogenic shock nursing NCLEX review of the treatment, nursing interventions, pathophysiology, and signs and symptoms. Menu and widgets. Urine output has been 30 mL/hr for the past 3 hours. 1. Options A, B, and C: Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries. Join NURSING.com and try SIMCLEX® (the most realistic NCLEX® simulation software) and NPQ™, the largest Nursing Practice Question Database. Which of the following nursing interventions should be done first? Spontaneous respirations 4. The nurse would avoid which of the following measures to minimize the risk of recurrence? All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. After hypophysectomy or removal of the pituitary gland, the body can’t synthesize ADH. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? Focus topic: Emergency Nursing . Option C: Dilantin shouldn’t be mixed in solution for administration. Options B, C, and D: If nursing measures prove ineffective notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy. The physician is notified immediately so that treatment can begin before respirations cease. Distributive shock, also known as vasodilatory shock, is one of the four broad classifications of disorders that cause inadequate tissue perfusion. 14. “Notify the physician immediately if he has a headache.”. 1. Neurogenic Shock Interventions. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. 3. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? Assess for bladder distention and bowel impaction. Rapid administration can depress the myocardium, causing arrhythmias. 3. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present. 2. 3. Extent of intracranial bleeding Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers Keeping the client flat on one side or the other, Elevating the head of the bed to 30 degrees, Log rolling or turning as a unit when turning. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. Percent of functional brain tissue. Option C: The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses. Autonomic dysreflexia However, cells are experiencing... 3. Anaphylactic Shock NCLEX Review, Lecture on Septic Shock All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. 2. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by the arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Test. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. Check deep tendon reflexes to determine the best motor response. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Suction the nose to maintain airway patency You will learn the following from this NCLEX review: This NCLEX review will discuss Parkinson’s disease. By performing the head-tilt, chin-lift maneuver. Bloody drainage from the ears Elevating the head of the bed to 30 degrees. Hemiparesis Option D: Slowing the rate of IV fluid would contribute to dehydration when polyuria is present. He has limited movement of his upper extremities. The nurse is caring for a client admitted with spinal cord injury. 1. a. 24. A headache is a symptom of autonomic dysreflexia, not a cause. You have not finished your quiz. is to ensure patients safety first then call for help. Deep tendon reflexes 3. Which of the following respiratory patterns indicate increasing ICP in the brain stem? When discharging him to the care of his mother, the nurse gives which of the following instructions? Which type of head injury does this finding suggest? Teach patient about the need for good oral hygiene. The nurse is caring for a client with a T5 complete spinal cord injury. The client momentarily lost consciousness at the time of the injury and then regained it. By inserting a oropharyngeal airway 1. Results in decreased cardiac output. 2. The other drugs aren’t indicated in this circumstance. Answer: 2. 3. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Emergency Nursing: Neurogenic (Spinal) Shock. Normal ICP is 15 mm Hg or less. Seizures 10. 33. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Lumbar spinal cord injury Distributive shock also leads to leakage of fluid from capillaries into the surrounding tissues, further complicating the … Answer: 2. After a hypophysectomy, vasopressin is given IM for which of the following reasons? A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client’s neurological status deteriorates quickly. 3. 1. Option C: Providing emollients to prevent skin breakdown is important, but doesn’t need to be performed immediately. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg. A client has signs of increased ICP. The client now has lost consciousness again. 1. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. An 18-year-old client is admitted with a closed head injury sustained in a MVA. An epidural hematoma occurs when blood collects between the skull and the dura mater. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. A CT scan of the head shows a collection of blood between the skull and dura mater. Spinal shock is also known as neurogenic shock. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. For hypovolemic shock is a day basis is said hypovolemic real workforce stress. 3. Absent corneal reflex. 1. 11. Give the client a warming blanket Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. Option A: Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client’s position slowly. Which of the following observations by the nurse indicates that spinal shock persists? Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. The questions for NCLEX-RN were last updated at Feb. 13, 2021. Headache A 20-year-old client who fell approximately 30’ is unresponsive and breathless. Which of the following conditions would most likely be suspected? Quadriplegia and loss of respiratory function An 18-year-old client was hit in the head with a baseball during practice. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be suspected without an injury. 6. True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are... 3. The nurse takes quick action, knowing this is compatible with: 1. “Watch him for keyhole pupil the next 24 hours.”, “Expect profuse vomiting for 24 hours after the injury.”, “Wake him every hour and assess his orientation to person, time, and place.”, “Notify the physician immediately if he has a headache.”. 8. The diaphragm is stimulated by nerves at the level of C4. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate. A 22-year-old client has suffered a spinal cord injury in which he is experiencing spinal shock and cannot feel his legs. 46. Quadriplegia with gross arm movement and diaphragmatic breathing, Quadriplegia and loss of respiratory function. Option A: Garbled speech is known as dysarthria. After a spinal cord injury, ascending cord edema may cause a higher level of injury. “Clean the meatus with soap and water.”. 4. She states that she woke up and noticed that the left side of her face was "not responding" when she tried to blink, smile, or speak. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. “Gently rotate the catheter during removal.”. Check for bladder distention Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? Answer: 3. Option D: A history of diarrhea is irrelevant. This quiz will test your knowledge on hypovolemic shock. Desmopressin (DDAVP, stimate). Option D: Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility. Spend your time wisely! Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Place the client in a supine position with legs elevated. 3. I hear that if someone starts having a seizure a bystander can even note the length of time of seizure, what kind of behaviors (like jerking, eye rolling, etc) are occurring… Choice A was just documentation. The nurse should loosen any tight clothing and then check for bladder distention. 3. A client with a C6 spinal injury would most likely have which of the following symptoms? Neurogenic shock 16. 26. The underlying cause of epidural hematoma is usually related to which of the following conditions? Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. Provide emollients to the skin to prevent breakdown, Slow down the IV fluids and notify the physician. 1. During this time it is important to be assessing for Neurogenic Shock which is a hemodynamic phenomenon that can happen within 30 minutes of the initial injury. A flattened abdomen 31. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action. 1. Search for: Recent Posts. 2. After reviewing these notes, don’t forget to take the quiz that contains anaphylactic shock NCLEX questions and to watch the lecture. 1. EXAM TIP: Never choose an option that leaves the patient alone. 3. Post-Traumatic Stress Disorders Practice Tests for NCLEX/CGFNS. 30. Paraplegia A client comes into the ER after hitting his head in an MVA. Check for bladder distention Logrolling the client on a firm mattress Correct Answer(s): C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient’s spinal cord. After reviewing these notes, don’t forget to take the quiz that contains cardiogenic NCLEX questions and to watch the lecture. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Hi Katie A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Wrap her hands in soft “mitten” restraints, Tuck her arms and hands under the draw sheet. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. Help a Fellow Nurse! Emergency Nursing: Hypovolemic Shock. 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. Place her in a jacket restraint 13. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia. Elevate the HOB to 90 degrees Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. 17. 25. Answer: 1.

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