Nokea
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
- A. Administer PRN analgesic medication
- B. Administer PRN antihypertensive medication
- C. Lower the head of the bed
- D. Palpate the client’s bladder
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.
You may also like to solve these questions
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
A client visiting a family planning clinic is suspected of having an STD. The most diagnostic test for all stages of treponema pallidum (syphilis) is the:
- A. Venereal Disease Research Lab (VDRL)
- B. Rapid plasma reagin (RPR)
- C. Florescent treponemal antibody (FTA-Abs)
- D. Thayer-Martin culture (TMC)
Correct Answer: C
Rationale: The FTA-Abs test is the most specific and diagnostic for all stages of syphilis. VDRL and RPR are non-treponemal tests that can have false positives, so A and B are incorrect. Thayer-Martin culture is used for gonorrhea, so D is incorrect.
An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?
- A. Have the client sign the operative permit immediately before the medications take effect
- B. Have the client's next of kin sign the permission form
- C. Ask the client if he/she is willing to undergo surgery, sign the form for the client, and indicate the nurse's name as witness to the client's verbal consent
- D. Report it to the physician so the surgery can be delayed until the client can legally sign a consent form
Correct Answer: D
Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.
A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?
- A. Describe the surroundings and the objects in the room to the client.
- B. Put up the side rails and have the client ask for help when getting out of bed for any reason.
- C. Describe the voices of the personnel to the client.
- D. Remove objects such as water pitchers and glasses from the immediate vicinity.
Correct Answer: A
Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.
The nurse is caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s
- A. anterior fontanel
- B. bilateral hearing
- C. pulse pressure
- D. Babinski reflex
Correct Answer: A
Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.