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A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
- A. Autonomic dysreflexia
- B. Bradycardia
- C. Central cord syndrome
- D. Spinal shock
Correct Answer: A
Rationale: Autonomic dysreflexia, a life-threatening exaggerated sympathetic response, can occur in spinal cord injuries above T6, causing severe hypertension.
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The nurse is teaching a client with a history of osteoarthritis about exercise. The nurse should tell the client to:
- A. Engage in low-impact activities
- B. Perform high-impact exercises
- C. Avoid all physical activity
- D. Lift heavy weights
Correct Answer: A
Rationale: Low-impact activities like swimming reduce joint stress in osteoarthritis, improving mobility and reducing pain.
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Cyanosis
- B. Increased respirations
- C. Sternal and subcostal retractions
- D. Decreased respirations
Correct Answer: C
Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.
A client is taking Rifadin (rifampin) 600 mg PO daily for pulmonary tuberculosis. The nurse should tell the client to:
- A. Take the medication with juice
- B. Expect red discoloration of the urine
- C. Take the medication before going to bed at night
- D. Take the medication only if night sweats occur
Correct Answer: B
Rationale: Rifampin causes harmless red-orange discoloration of urine, sweat, and tears, which clients should be informed about to avoid alarm. It can be taken with or without food, timing is not restricted to bedtime, and it is taken daily, not conditionally.
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
- A. Liver and onions, macaroni and cheese, tea with sugar
- B. Baked chicken, baked potato with bacon bits, milk
- C. Waffles with butter and honey, orange juice
- D. Cheese omelette with ham and mushrooms, milk
Correct Answer: C
Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which intervention is most appropriate to prevent toxicity?
- A. Monitor respiratory rate
- B. Assess deep tendon reflexes
- C. Measure urine output
- D. All of the above
Correct Answer: D
Rationale: Magnesium sulfate toxicity can cause respiratory depression loss of reflexes and reduced urine output. Monitoring respiratory rate reflexes and urine output is essential to detect toxicity early and ensure patient safety.