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A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?
- A. Determine if the urinary bladder is distended
- B. Irrigate the indwelling urinary catheter
- C. Review the temperature graph for the last day
- D. Administer an antihypertensive agent
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.
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A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?
- A. Cramping muscular pain
- B. Worming movements of the tongue
- C. Decreased tendon reflexes
- D. Dry oral mucous membranes
Correct Answer: B
Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.
Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client's dressing. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Sore throat when swallowing
- B. Tongue deviation to the left
- C. Palpable temporal pulses
- D. Temperature of 99.2°F (37.3°C)
Correct Answer: B
Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Assess the client's need for pain medication
- B. Document the impending signs of death
- C. Inform the nurse manager of the client's status
- D. Communicate the client's status to the chaplain
Correct Answer: A
Rationale: Assessing the client's need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.
At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client's electronic health record, which priority nursing action should the nurse implement?
- A. Administer insulin based on the sliding scale
- B. Assess the appearance of the foot wound
- C. Obtain antibiotic peak and trough levels
- D. Initiate hourly measurements of urine output
Correct Answer: B
Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (Choice A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (Choice C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (Choice D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
- A. Encourage the use of corrective lenses during the day
- B. Practice visual exercises that focus on a still object
- C. Alternate an eye patch from eye every 2 hours
- D. Teach techniques for scanning the environment
Correct Answer: D
Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.