Question

injury. Which of the following should be included in the teaching? (Select all that apply) a. Place the patient on seizure precautions b. Position the patient in the supine position c. Monitor the patient for nausea and/or vomiting d. Monitor the patient for bradycardia e. Monitor the patient for heart failure TTA 42. A nurse is teaching a group of new graduate nurses about the care of a patient with a head 43. The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. Obtain a specimen of the fluid and send for culture and sensitivity b. Take the patient's temperature to deternmine whether a fever is present c. Check the nasal drainage for glucose with a dextrostik or test-tape d. Have the patient blow the nose and check the nares for redness 44. A 24 year old patient is hospitalized with the onset of Guillain Barre Syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. Monitoring the cardiac rhythm continuously b. Determining the level of consciousness every 2 hours c. Evaluating sensation and strength of the extremities d. Performing frequent evaluation of respiratory function 45. The nurse is teaching a patient who has been diagnosed with myasthenia gravis. Which of the following is an appropriate statement by the nurse? "The disease is caused by avirus and your symptoms are not permanent. b. "Your muscle weakness will improve throughout the day. c. "Your muscle weakness may be worse in the evening. d. The disease will not lead to an a. inability to perform ADL's." 46. Indicate what each position is

Answer 1

42. The correct option are :-

a) place the patient on seizure precautions because due to head injury patient might have seizures , to avoid that put him on seizure precautions .

c ) Monitor the patient for nausea and vomiting , because head injury can cause increased intracranial pressure and nausea and vomiting are the signs and symptoms of raised ICP .

d) Monitor the patient for bradycardia because raised ICP causes bradycardia .

43. The correct option is c ) check the nasal discharge for glucose with a dextrostrik or test - tape for confirming whether it is cerebrospinal fluid or not .

44. The correct option is d ) performing frequent evaluation of respiratory function . There is an ascending weakness in Guilliane Barre Syndrome and the nurse should continously assess for respiratory functioning .

45. The correct option is c ) your muscle weakness may be worse in the evening , it is seen as a symptom in Myasthenia gravis .

46. Image 1 is Decroticate posture

damage to one or both corticospinal tracts. arms adducted and flexed, wrist and fingers flexed on the chest. legs stiffly extended with feet in plantarflexion.

Image 2 is Decerebrate posture

damage to the upper brainstem. arms adducted and extended, wrists pronated and fingers flexed. legs are stiffly extended, feet plantar flexed