Nokea
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
- A. administer nitrate or nifedipine
- B. check the client for fecal impaction
- C. check the client for bladder distention
- D. place the bed in high Fowler's position
Correct Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by bladder distention in spinal cord injuries above T6. Checking and relieving bladder distention is the priority.
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The nurse is assessing the reflexes of a full-term newborn infant. Which of the following is true regarding newborn reflexes?
- A. The Babinski reflex disappears after 1 year of age.
- B. Complete fencing response disappears by 2 months.
- C. The stepping or 'walking' reflex is present until 3-4 months.
- D. The Moro reflex is present at birth and disappears by 6 months.
Correct Answer: D
Rationale: The Moro reflex, present at birth, typically disappears by 6 months. Babinski persists until ~2 years, fencing (tonic neck) until 4-6 months, and stepping until 1-2 months.
The nurse is caring for a client with bulimia nervosa. The nurse recognizes that the major difference in the client with anorexia nervosa and the client with bulimia nervosa is the client with bulimia:
- A. Is usually grossly overweight.
- B. Has a distorted body image.
- C. Recognizes that she has an eating disorder.
- D. Struggles with issues of dependence versus independence.
Correct Answer: C
Rationale: Clients with bulimia often recognize their eating disorder, unlike those with anorexia, who may deny the problem due to distorted body image.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Administer a bronchodilator as ordered.
- C. Place the client in a high Fowler’s position.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: C
Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?
- A. The medication can cause dental staining.
- B. The client will need to avoid a high-carbohydrate diet.
- C. The client will need a regularly scheduled blood work.
- D. The client will need a regularly scheduled blood work.
Correct Answer: C
Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
- A. Confirm that all staff members understand and comply with the treatment plan.
- B. Establish mutually agreed upon, realistic goals.
- C. Ensure that the potent reinforcers (rewards) are important to the client.
- D. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program