Question

6. A patient with Multiple Sclerosis spends most of the day in a wheelchair or bed except for assisted ambulation and elimination needs with a rehabilitation nurse. The primary nursing diagnosis for this patient is: a. Risk for alteration in skin integrity b. Risk for nutrition: more than body requirements c. Risk for diarrhea d. Risks for alteration in thought process 7. The nurse is caring for a young male diagnosed with Amyotrophic Lateral Sclerosis (ALS). His disease is progressing and is now bed bound requiring mechanical ventilation. The priority nursing diagnosis for this patient is: a. Alteration in perfusion: capillary refill of 2 seconds b. Alteration in elimination: constipation c. Alteration in cognitive status d. Alteration in respiratory status: risk for infection 8. An emergency room nurse is assessing an 18 year old home from college. Temperature of 102.2, severe headache and complaining of a stiff neck. Based on her assessment, the nurse suspects: a. Influenza no b. Bacterial meningitis c. Concussion d. Sinus infection 9. A nurse is assessing her patient and documents the following. Ascending, symmetric weakness of the limbs. Reflexes not present. Patient was previously treated for an upper respiratory infection. These clinical findings are consistent with: a. Multiple Sclerosis b. Amyotrophic Lateral Sclerosis c. Guillaine Barre d. Brain tumor 10. During admission of a patient with a severe head injury. The nurse knows the highest priority nursing intervention is: a. To maintain patency of the airway b. Immobilize the cervical spine c. Assess neurologic status using the Glascow Coma Scale d. Position the patient supine on the left side

Answer 1

6. The correct option is a ) Risk for alteration in skin integrity because the patient spends most of the time on bed or wheelchair . It will result in the formation of pressure ulcers .

7. The correct option is d ) Alteration in respiratory status : risk for infection because the patient requires mechanical ventilation and it will cause alteration in the respiratory process and also can cause ventilator associated infection commonly VAP .

8. The correct option is b) Bacterial meningitis because the symptoms resembles the sign and symptoms of meningitis . Stiff neck , fever , kernig's sign , brudzinki 's sign , photophobia are the cheif symptoms of meningitis .

9. The correct option is c ) Guilliane Barre because ascending weakness is the main sign and symptom of Guilliane Barre .

10. The correct option is b) immobilize the cervical spine because there might be chances of cervical injury .