The client has an incomplete upper motor neuron lesion. What complication should the nurse be alert for in this client?
A. Contractures
B. Hyperreflexia
C. Hypotension
D. Visual disturbances
A
Individuals with upper motor neuron lesions have muscle spasticity that can lead to contractures once spinal shock has resolved.
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To examine the palpebral conjunctiva of the upper lid, which of the following steps would be included? Select all that apply
a. Ask the person to keep both eyes open and look down to relax the levator muscle. b. Gently pull the upper eyelash down. c. Place a cotton tip applicator about 1 cm above the lid margin. d. Gently push down with the stick as you lift the lash upward to evert the lid. e. Inspect for color change, swelling, lesion, or foreign body. f. Return the lid to the normal position by pulling the eyelid outward as the person looks up.
What is required to maintain fluid balance between the intracellular and extracellular compartments?
a. There is a constant exchange of water be-tween the compartments. b. The hypothalamus sends each compartment messages regarding the need for retaining or releasing fluid to the cells. c. The kidneys retain and excrete fluid as needed for fluid balance. d. The lymph nodes throughout the body regulate fluid balance.
A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient?
1. Class 3 minor 2. Class 1 minor 3. Class 1 penetrating 4. Class 3 penetrating
Which of the following is the most likely cause of bloody discharge from the nipple?
A) Breast cancer B) Interductal papilloma C) Fibrocystic breast disease D) Side effect of medication