Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is most ...

Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?
 
  a. Nasogastric tube feeding q4hr
  b. Artificial tear administration q2hr
  c. Assessment for bladder distention q2hr
  d. Passive range of motion to extremities q4hr

Question 2

A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
 
  a. The patient has new onset weakness of both legs.
  b. The patient complains of chronic severe back pain.
  c. The patient starts to cry and says, I feel hopeless.
  d. The patient expresses anxiety about having surgery.

Question 3

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach. Which action should the nurse take first?
 
  a. Check for a fecal impaction.
  b. Give the prescribed analgesic.
  c. Assess the blood pressure (BP).
  d. Notify the health care provider.

Question 4

Before administering botulinum antitoxin to a patient in the emergency department, it is most important for the nurse to
 
  a. obtain the patient's temperature.
  b. administer an intradermal test dose.
  c. document the neurologic symptoms.
  d. ask the patient about an allergy to eggs.

Question 5

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to
 
  a. administer humidified oxygen by mask.
  b. suction the patient's mouth and nasopharynx.
  c. push upward on the epigastric area as the patient coughs.
  d. encourage incentive spirometry every 2 hours during the day.

Question 6

A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is
 
  a. determining level of consciousness.
  b. checking strength of the extremities.
  c. observing respiratory rate and effort.
  d. monitoring the cardiac rate and rhythm.

Question 7

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury?
 
  a. Cardiac monitoring for bradycardia
  b. Assessment of respiratory rate and effort
  c. Application of pneumatic compression devices to legs
  d. Administration of methylprednisolone (Solu-Medrol) infusion

Question 8

A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation.
 
  The most appropriate action by the nurse at this time is to
  a. remind the patient about the importance of independence in daily activities.
  b. tell the spouse to stop because the patient is able to perform activities independently.
  c. develop a plan to increase the patient's independence in consultation with the patient and the spouse.
  d. recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.