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
The nurse has reinforced teaching with a client who has gout. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Drink plenty of fluids, including at least 2 L of water daily
- B. Reduce your consumption of alcohol or abstain from drinking
- C. Take aspirin instead of acetaminophen for minor pain or discomfort
- D. Implement a diet and physical activity regimen to maintain a healthy weight
- E. Select protein sources that are low in purine, such as low-fat dairy products
Correct Answer: A,B,D,E
Rationale: Fluids, reduced alcohol, weight management, and low-purine proteins reduce uric acid and gout flares. Aspirin can increase uric acid levels, worsening gout, and should be avoided.
The women’s health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?
- A. Client reports heavy menstrual cycles
- B. History of breast cancer in maternal aunt
- C. History of deep venous thrombosis
- D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m^2
Correct Answer: C
Rationale: Deep venous thrombosis is a contraindication for estrogen-containing contraceptives like the patch due to increased clotting risk. Heavy menses, family history of breast cancer, and obesity are less critical.
A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?
- A. Prepare for a throat culture
- B. Schedule him for an appointment later in the day
- C. Isolate and alert the physician immediately
- D. Obtain a urine specimen
Correct Answer: C
Rationale: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.
A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?
- A. Increased pain caused by the release of histamine
- B. Blanching of the skin proximal to the laceration
- C. A decrease in the white blood count
- D. Granulation of tissue at the edges of the laceration
Correct Answer: A
Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.
The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to
- A. place the client in the semi-Fowler position
- B. record the characteristics of the dialysate output
- C. use sterile technique when spiking and attaching the bag of dialysate
- D. ensure that the drainage collection bag is below the level of the abdomen
Correct Answer: C
Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.