Nokea
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
- A. Notify the RN.
- B. Assess the client for a distended bladder.
- C. Apply oxygen at 3 L/min.
- D. Increase the IV fluids.
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.
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A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?
- A. She is in an early stage of normal grief.
- B. She may be hallucinating.
- C. She may be having illusions.
- D. She may be in a severe depression.
Correct Answer: A
Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.
A client is admitted to the neurology unit for a myelogram.
It would be MOST important for the nurse to ask which of the following questions?
- A. Do you have any allergies?'
- B. Have you been drinking lots of fluids?'
- C. Are you wearing any metal objects?'
- D. Are you taking medication?'
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned children.'
- B. Port wine stains are often associated with other malformations.'
- C. Telangiectatic nevi are normal and will disappear as the baby grows.'
- D. The child is too young for consideration of surgical removal of these at this time.'
Correct Answer: C
Rationale: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years.
An adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also.adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also complains of tingling around the mouth and in the fingers and toes. What should the nurse expect to do initially?
- A. Administer oxygen
- B. Have the client breathe into a paper bag
- C. Call the physician immediately
- D. Encourage the client to do deep breathing exercises
Correct Answer: B
Rationale: Tachypnea and tingling suggest hyperventilation causing respiratory alkalosis; breathing into a paper bag restores CO2 levels, correcting pH.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions should the nurse prioritize?
- A. Encourage early ambulation.
- B. Administer pain medication as needed.
- C. Keep the affected leg in adduction.
- D. Monitor the incision for drainage.
Correct Answer: A
Rationale: Early ambulation prevents complications like thrombosis and promotes recovery. Options B, C, and D are secondary or incorrect.