A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

Surgery to remove the eye

Referral for drug rehabilitation program

Admission for IV and intravitreal antibiotics

Follow up with eye specialist outpatient

Answer and Explanation

The Correct Answer is C

A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.

B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.

C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.

D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.

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Correct Answer is D

Explanation

A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.

B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.

C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.

D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.

A. Frequent passive range of motion B. Coughing and deep breathing exercises once per shift C. Turn patient every 4 hours D. Ambulate patient twice per shift

Correct Answer is A

Explanation

A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.

B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.

C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.

D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.

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A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

Correct Answer is D

Explanation

The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Correct Answer is A

Explanation

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

The nurse is teaching a patient who is prescribed valproic acid for seizures. The nurse would identify that the patient understands the teaching for the medication when they state, "I will notify my healthcare provider if I experience:

A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:

The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder. The nurse would provide discharge education to the patient and family regarding which bladder management technique?

A 24-year-old patient who is an intravenous drug user asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). The nurse informs the patient that the risk of developing the human immunodeficiency virus (HIV) infection from drug use can be reduced by: