Nokea
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
- A. Dizziness and tachypnea
- B. Circumoral pallor and lightheadedness
- C. Headache and facial flushing
- D. Pallor and itching of the face and neck
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.
You may also like to solve these questions
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results showing minimal bacteria
- B. Cloudy, foul-smelling urine
- C. White blood cell count of 14,000/mm3
- D. Temperature elevation of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures indicates no localized infection, supporting the outcome. Cloudy urine (B), elevated WBC (C), and fever (D) suggest possible infection.
The patient states, 'My stomach hurts about two hours after I eat.' Based upon this information, the nurse suspects the patient likely has a:
- A. Gastric ulcer
- B. Duodenal ulcer
- C. Peptic ulcer
- D. Curling's ulcer
Correct Answer: B
Rationale: Pain 2–3 hours after eating is characteristic of a duodenal ulcer, as acid irritates the ulcerated mucosa in the duodenum post-digestion. Gastric ulcer pain typically occurs sooner after meals, peptic ulcer is a general term, and Curling’s ulcer is stress-related.
Which set of vital signs would best indicate to the nurse that a client has an increase in intracranial pressure?
- A. BP 180/70, pulse 50, respirations 16, temperature 101°F
- B. BP 100/70, pulse 64, respirations 20, temperature 98.6°F
- C. BP 96/70, pulse 132, respirations 20, temperature 98.6°F
- D. BP 130/80, pulse 50, respirations 18, temperature 99.6°F
Correct Answer: A
Rationale: Increased ICP is indicated by Cushing’s triad: hypertension (BP 180/70), bradycardia (pulse 50), and irregular respirations. Option A best matches this, with fever as a possible secondary sign. Options B, C, and D lack this combination.
The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?
- A. Fetal hypoglycemia
- B. Maternal tachycardia
- C. Fetal macrosomia
- D. Maternal hypokalemia
Correct Answer: B
Rationale: Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. Prolonged bed rest
- B. The client's maintaining a semi-Fowler position
- C. Cerebral hypoxia
- D. IV fluids of 2.5-3 liters in 24 hours
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.