AH IV Exam 4 Questions With Correct
Answers
A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The
nurse should include which interventions to maintain client safety after this procedure? Select all
that apply.
1.Use the overhead trapeze.
2.Keep the head...
A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The
nurse should include which interventions to maintain client safety after this procedure? Select all
that apply.
1.Use the overhead trapeze.
2.Keep the head of the bed flat.
3.Place pillows under the length of the legs.
4.Use a logrolling technique for repositioning.
5.Assist the client with eating meals and drinking fluids. - answer✔✔2345
After a client has spinal fusion, the head of the bed generally is kept flat. Because the client is in
the flat position, the nurse should assist the client with eating meals and drinking fluids. The
client is logrolled from side to side as prescribed. Pillows may be placed under the entire length
of the legs, in accordance with surgeon preference, to relieve tension on the lower back. The use
of an overhead trapeze may decrease control of spinal movement and is contraindicated because
its use could promote twisting of the spine after surgery
The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is
complaining about stabbing pain radiating to the lower back and the right buttock. The nurse
determines that the client's signs/symptoms are most likely due to which condition?
1.Pressure on the spinal cord
2.Pressure on the spinal nerve root
3.Muscle spasm in the area of the herniated disk
4.Excess cerebrospinal fluid production in the area - answer✔✔3. Compression of a nerve results
in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of
muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on the spinal
cord itself could result in a variety of manifestations, depending on the area involved. Pressure
on a spinal nerve root causes the symptoms of sciatica.
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed
rest in Williams' position to minimize the pain. The nurse should put the bed in what position?
1.Flat with the knees raised
2.In high-Fowler's position, with the foot of the bed flat
3.In semi-Fowler's position, with the foot of the bed flat
4.In semi-Fowler's position, with the knees slightly flexed - answer✔✔4. Clients with low back
pain often are more comfortable when placed in Williams' position. The bed is placed in semi-
Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the
muscles of the lower back and relieves pressure on the spinal nerve root. The remaining positions
will not minimize the pain and may make the pain worse.
A client has been prescribed cyclobenzaprine for the treatment of painful muscle spasms
accompanying a herniated intervertebral disk. The nurse should withhold the medication and
question the prescription if the client has a concurrent prescription for which medication?
1.Ibuprofen 2.Furosemide 3.Valproic acid 4.Tranylcypromine - answer✔✔4.The client should
not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors such as
tranylcypromine or phenelzine within the last 14 days. Otherwise, the client could experience
hyperpyretic crisis, seizures, and possibly death. The medications in the remaining options are
not contraindicated.
The nurse is caring for the client with increased intracranial pressure as a result of a head injury?
The nurse would note which trend in vital signs if the intracranial pressure is rising?
1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure -
answer✔✔2. A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse determines that the
client understands measures to prevent elevations in intracranial pressure if the nurse observes
the client doing which activity?
1.Blowing the nose
2.Isometric exercises
3.Coughing vigorously
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
4.Exhaling during repositioning - answer✔✔4. Activities that increase intrathoracic and
intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these
activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the
nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis,
which prevents intrathoracic pressure from rising.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse
should include which measures in the plan of care to minimize the risk of occurrence? Select all
that apply.
1.Keeping the linens wrinkle-free under the client
2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once
every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the
client has a bowel movement at least once a week - answer✔✔124. The most frequent cause of
autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6
hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked
frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so
maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too
infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli.
The nurse administers care to minimize risk in these areas.
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord
injury. Which observation indicates that spinal shock persists?
1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder -
answer✔✔3. Resolution of spinal shock is occurring when there is return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex
emptying of the bladder.
A client with myasthenia gravis has become increasingly weaker. The primary health care
provider prepares to identify whether the client is reacting to an overdose of the medication
(cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of
edrophonium is administered. Which finding would indicate that the client is in cholinergic
crisis?
1.No change in the condition
2.Complaints of muscle spasms
3.An improvement of the weakness
4.A temporary worsening of the condition - answer✔✔4. An edrophonium injection makes the
client in cholinergic crisis temporarily worse. An improvement in the weakness indicates
myasthenia crisis. Muscle spasms are not associated with this test.
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