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A client with a spinal cord injury suddenly develops a throbbing headache, nasal congestion, and a blood pressure of 210/110 mm Hg. Which action should the nurse perform first?
- A. Administer a prescribed antihypertensive
- B. Check the client's bladder for distention
- C. Place the client in a supine position
- D. Notify the healthcare provider
Correct Answer: B
Rationale: Symptoms (headache, congestion, BP 210/110) indicate autonomic dysreflexia; checking bladder distention (B) identifies the trigger first. Medication (A) or supine (C) is secondary. Notification (D) follows. B is correct. Rationale: Removing the stimulus (e.g., bladder) halts dysreflexia, a priority per SCI protocols, preventing hypertensive crisis.
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The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by
- A. Vasoconstriction
- B. Vasodilatation
- C. Decreases force of contractility
- D. Decreases cardiac output
Correct Answer: B
Rationale: The coronary vessels are unique because they respond to sympathetic stimulation with vasodilatation, unlike most other blood vessels which constrict. Sympathetic stimulation activates the fight-or-flight response, increasing heart rate and oxygen demand. To meet this demand, the coronary arteries dilate to supply more blood to the heart muscle. Vasoconstriction (A) is incorrect as it would reduce blood flow, countering the heart's needs during stress. Decreases in force of contractility (C) or cardiac output (D) are unrelated to the vascular response and pertain more to myocardial function, not the coronary vessels' behavior. This vasodilatation is mediated by beta-adrenergic receptors, ensuring adequate perfusion during heightened activity, making B the correct choice.
A nurse uses an institution's procedure manual to confirm how to insert a nasogastric tube. The level of critical thinking the nurse is using is:
- A. Basic critical thinking
- B. Commitment
- C. Complex critical thinking
- D. Scientific method
Correct Answer: A
Rationale: Basic critical thinking involves following established guidelines or procedures, like using a manual for nasogastric tube insertion, typical for novices relying on concrete rules. The nurse here seeks confirmation, indicating dependence on external standards rather than independent judgment. Commitment reflects decisive action based on internalized reasoning, not manual reliance. Complex critical thinking analyzes and adapts procedures (e.g., modifying technique for patient anatomy), requiring experience beyond rote steps. The scientific method tests hypotheses, not applicable to routine protocol checks. Basic critical thinking suits this scenario, as the nurse applies learned steps without deviation, a foundational level ensuring safe practice while building toward higher-order skills in dynamic clinical settings.
Marianne is now at the Defervescence stage of the fever, which of the following is expected?
- A. Delirium
- B. Goose flesh
- C. Cyanotic nail beds
- D. Sweating
Correct Answer: D
Rationale: Defervescence, fever's decline, involves vasodilation and sweating e.g., cooling as heat dissipates. Delirium (high fever), goose flesh (chills), or cyanosis (hypoxia) don't fit. Nurses anticipate sweating e.g., damp sheets in Marianne, adjusting care for comfort, per fever resolution stages.
After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?
- A. Serum osmolality increases
- B. Urine concentration decreases
- C. Glomerular filtration decreases
- D. Tubular reabsorption of water increases
Correct Answer: B
Rationale: ADH deficiency (diabetes insipidus) post-head injury causes dilute urine (B) due to reduced water reabsorption. Osmolality increases (A) is a result, not a cause. GFR (C) isn't primarily affected. Reabsorption (D) decreases. B is correct. Rationale: Low ADH leads to polyuria with low urine concentration, a key assessment in DI, per endocrine trauma care.
A nurse provides care to clients of a community clinic that serves a large immigrant population. Which intervention reflects primary prevention for this group?
- A. Screening for tuberculosis
- B. Providing vaccinations
- C. Referring clients with hypertension to a specialist
- D. Teaching clients with diabetes foot care
Correct Answer: B
Rationale: Primary prevention stops illness before it starts, vital for immigrants facing unique risks. Providing vaccinations like measles or flu shots builds immunity, preventing outbreaks in a group often under-vaccinated due to access or prior country norms, a top nursing action in clinics. Screening for tuberculosis is secondary, catching disease early, common in immigrant health but not preventive. Referring hypertension cases or teaching diabetic foot care is tertiary, managing existing conditions, not averting onset. Vaccinations align with primary prevention's proactive stance data shows they cut infectious disease rates in such populations addressing environmental and social vulnerabilities. Nursing leverages this to protect community health, ensuring immigrants, often in crowded settings, dodge preventable illnesses, a practical, impactful step for this clinic's focus.