ATI MEDSURG 2 NUR 265/DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE 2024/2025.

ATI MEDSURG 2 NUR 265/DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE 2024/2025.

A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected
cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that
apply.)
A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex
Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood
pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately
perfuse the spinal cord.

Polyuria is incorrect. The nurse should check the
client for bladder distention and inability to urinate due to ineffective function of the bladder
muscles.

Hyperthermia is incorrect. The nurse should monitor the client for
hypothermia caused by a lack of lack of sympathetic input.

Absence of bowel
sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client
to develop a paralytic ileus.

Weakened gag reflex is correct. The nurse should
monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.
2.A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which
of the following statements by the client indicates a need for further teaching?
A. "I will notify my doctor before taking any other medications."
Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should be
notified that the client is taking phenytoin.
B. "I have made an appointment to see my dentist next week."
Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dental
monitoring important.
C. "I know that I cannot switch brands of this medication."
Rationale: The client understands that bioavailability varies with different brands, so no substitutions should
be made.
D. "I'll be glad when I can stop taking this medicine."
Rationale: Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant
medications commonly require them for lifetime administration, and phenytoin should not be
stopped without the advice of the client's provider.
3.A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new
Detailed Answer Key
Neuro-Shock & Burns practice
prescription for timolol eye drops. Which of the following instructions should the nurse provide?
A. The medication is to be applied when the client is experiencing eye pain.
Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserve
remaining eyesight.
B. The medication will be used until the client's intraocular pressure returns to normal.
Rationale: Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen the
client's condition.
C. The medication should be applied on a regular schedule f