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kunci jawaban 2.docx

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  1.D Klien yang mempunyai riayat infeksi streptokous dapat menyebabkan antibodi memroduksi streptokinase tidak efektif. Terapi streptokinase berarti sebelumnya terkena streptokokus , infeksi pling umum yang menyebabkan radang tenggorokan dan nyeri menelan 2.B 3. B . The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be verified by diagnostic tests prior to administering it. rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified; rt-PA is not given if the client is experiencing a hemorrhagic stroke. 2. Teaching is important to help prevent another CVA, but it is not the priority intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching. 3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment. 4. The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not priority in the emergency department. TEST- TAKING HINT: When “priority” is used  in the stem, all answer options may be appropriate for the client situation, but only one option is priority. The client must have a documented diagnosis before treatment is started. Content  –  Medical: Category of Health Alteration  –  Neurological: Integrated Nursing Process  –  Implementation: Client Needs  –  Safe Effective Care Environment, Management of Care: Cognitive Level  –  Synthesis. 4. D objects; therefore, observing the client for possible aspiration is not appropriate. 2. A semi-Fowler ’ s position is appropriate for sleeping, but agnosia is the failure to recognize familiar objects; therefore, this  intervention is inappropriate. 3. Placing suction at the bedside will help if the client has dysphagia (difficulty swallowing), not agnosia, which is failure to recognize familiar objects. 4.  A collaborative intervention is an intervention in which another health-care discipline — in this case, occupational therapy — is used in the care of the client. TEST-TAKING HINT: Be sure to look at what the question is asking and see if the answer can be determined even if some terms are not understood. In this case, note that the question refers to “collaborative intervention.”   Only option “4” refers to collaboration  with another discipline. 5. C 9. 1. Potential for injury is a physiological problem, not a psychosocial problem. 2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless. 3. A disturbance in thought processes is a cognitive problem; with expressive aphasia the client ’ s thought processes are intact. 4. Sexual dysfunction can have a psychosocial component or a physical component, but it is not related to expressive aphasia. TEST-TAKING HINT: The test taker should always make sure that the choice selected as the correct answer matches what the question is asking. The stem has the adjective “psychosocial,” so the correct   answer must address psychosocial needs. Content –   Medical: Category of Health Alteration –   Neurological: Integrated Nursing Process –   Diagnosis: Client Needs –   Psychosocial Integrity: Cognitive Level –   Analysis 6 D 1. Assessment is important, but with clients with head injury the nurse must assume  spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority. 2. Removing the client from the water is an appropriate intervention, but the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority. 3. Assessing the client for further injury is appropriate, but the first intervention is to stabilize the spine because the impact was strong enough to render the client unconsciousness. 4. The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis; therefore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water. TEST-TAKING HINT: When two possible answer options contain the same directive word —in this case, “assess”— the test taker can either rule out these two as incorrect or prioritize between the two assessment responses. 7. C 1. The client is at risk for seizures and does not process information appropriately. Allowing him to return to his occupation as a forklift operator is a safety risk for him and other employees. Vocational training may be required. 2. “Cognitive” pertains to me ntal processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes. 3. The client ’ s ability to dress self addresses self-care problems, not a cognitive problem. 4. The client ’ s ability to regain bowel and bladder control does not address cognitive deficits    8. B 1. Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected. 2. Assessment of the movement of the upper extremities would be more appropriate with a higher level injury; an injury in the cervical area might cause an inability to move the upper extremities. 3. Complaints of a pounding headache are not typical of a T12 spinal injury. 4. Hypotension (low blood pressure) and tachycardia (rapid heart rate) are signs of    hypovolemic or septic shock, but these do not occur in spinal shock. TEST-TAKING HINT: If the test taker does not have any idea what the answer is, an attempt to relate the anatomical position of keywords in the question stem to words in the answer options is appropriate. In this case, T12, mentioned in the stem, is around the waist, so answer options involving the anatomy above that level (e.g., the upper extremities) can be eliminated. Content –   Medical: Category of Health Alteration –   Neurological: Integrated Nursing Process –    Assessment: Client Needs –   Safe Effective Care Environment, Management of Care: Cognitive Level –   Analysis 9. B 1. Oxygen is administered initially to maintain a high arterial partial pressure of oxygen (PaO 2 ) because hypoxemia can worsen a neurological deficit to the spinal cord initially, but this client is in the rehabilitation department and thus not in the initial stages of the injury. 2. Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox)
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