Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 17-year old was injured after diving into shallow water. He was transported to the emergency department where imaging indicated he suffered a spinal cord injury. Based on this information, what mechanism likely caused the spinal cord injury?
A. hyperextension
Rationale: hyperextension is when the neck is bent backward beyond its normal range of motion. This can happen in a rear-end collision or a fall on the back of the head.
B. compression
Rationale: A spinal cord injury occurs when there is damage to the spinal cord or the surrounding structures, such as the vertebrae, ligaments, or discs. The most common cause of spinal cord injury is trauma, which can result from direct impact, penetration, or excessive force on the spine. Diving into shallow water can cause compression of the spine, which means that the vertebrae are pushed together and squeeze the spinal cord. This can damage the nerve fibers and disrupt the communication between the brain and the body. Compression injuries can affect any part of the spine, but are more common in the cervical and thoracic regions.
C. flexion-rotation
Rationale: flexion-rotation is when the neck is bent and twisted at the same time. This can happen in a sports injury or a violent assault.
D. flexion
Rationale: This is when the neck is bent forward beyond its normal range of motion. This can cause the posterior part of the vertebral column to compress and fracture, while the anterior part of the spinal cord is stretched and injured. This can happen in a head-on collision or a fall on the face. A flexion-rotation is when the neck is bent and twisted at the same time.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Paediatrics Proctored Exam 1. Take the full exam now
Full Explanation
Choice A Rationale: hyperextension is when the neck is bent backward beyond its normal range of motion. This can happen in a rear-end collision or a fall on the back of the head.
Choice B Rationale: A spinal cord injury occurs when there is damage to the spinal cord or the surrounding structures, such as the vertebrae, ligaments, or discs. The most common cause of spinal cord injury is trauma, which can result from direct impact, penetration, or excessive force on the spine. Diving into shallow water can cause compression of the spine, which means that the vertebrae are pushed together and squeeze the spinal cord. This can damage the nerve fibers and disrupt the communication between the brain and the body. Compression injuries can affect any part of the spine, but are more common in the cervical and thoracic regions.
Choice C Rationale: flexion-rotation is when the neck is bent and twisted at the same time. This can happen in a sports injury or a violent assault.
Choice D Rationale: This is when the neck is bent forward beyond its normal range of motion. This can cause the posterior part of the vertebral column to compress and fracture, while the anterior part of the spinal cord is stretched and injured. This can happen in a head-on collision or a fall on the face. A flexion-rotation is when the neck is bent and twisted at the same time.
Similar Questions
A client diagnosed with severe Alzheimer's has been admitted to a long term care facility. Which of the following are appropriate activities for the nurse to include in the care plan?
A. Simple puzzles
Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
B. Board games
Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
C. Dangling ribbons or a mobile
Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
D. Drawing with crayons
Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
Full Explanation
Choice A Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
Choice B Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
Choice C Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
Choice D Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
When asked to explain the common symptoms of Bell's Palsy, the nurse correctly identifies which of the following as manifestations of this disorder?
A. Ringing in the ears that occurs more frequently in the early morning
Rationale: Ringing in the ears (tinnitus) is not a common symptom of Bell's Palsy. Bell's Palsy primarily affects facial muscles.
B. Bilateral pain from the neck upward
Rationale: Bilateral pain from the neck upward is not a typical manifestation of Bell's Palsy. Bell's Palsy typically affects one side of the face.
C. Progressive loss of ability to use all facial muscles
Rationale: Progressive loss of ability to use all facial muscles is not the usual pattern of Bell's Palsy. It typically presents with sudden unilateral weakness of the face.
D. Sudden unilateral weakness of the face
Rationale: Sudden unilateral weakness of the face is a hallmark symptom of Bell's Palsy. This condition often causes weakness or paralysis of the facial muscles on one side of the face, leading to facial drooping.
Full Explanation
Choice A Rationale: Ringing in the ears (tinnitus) is not a common symptom of Bell's Palsy. Bell's Palsy primarily affects facial muscles.
Choice B Rationale: Bilateral pain from the neck upward is not a typical manifestation of Bell's Palsy. Bell's Palsy typically affects one side of the face.
Choice C Rationale: Progressive loss of ability to use all facial muscles is not the usual pattern of Bell's Palsy. It typically presents with sudden unilateral weakness of the face.
Choice D Rationale: Sudden unilateral weakness of the face is a hallmark symptom of Bell's Palsy. This condition often causes weakness or paralysis of the facial muscles on one side of the face, leading to facial drooping.
When educating a client about tetanus, which of the following will the nurse include in teaching? Select All that Apply
A. Affects only the spinal cord
Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.
B. Manifestations include sustained muscle contractions
Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.
C. Follows a recent viral infection
Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.
D. Bacteria is found in improperly processed foods
Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.
E. Spores are found in soil, gardens, and manure
Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.
Full Explanation
Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.
Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.
Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.
Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.
Choice E Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.