Nokea
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
- A. Heart rate of 34 beats/min
- B. Blood pressure of 90/60 mm Hg
- C. Cool and clammy skin
- D. Decreased urinary output
- E. Flaccid paralysis below the injury
Correct Answer: A,B,C,D,E
Rationale: Neurogenic shock from a T5 spinal cord injury can cause bradycardia (low heart rate), hypotension (low blood pressure), cool and clammy skin, decreased urinary output due to reduced perfusion, and flaccid paralysis below the injury level.
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A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?
- A. Associated stridor.
- B. Weak pedal pulses.
- C. Difficulty breathing.
- D. Inability to shrug shoulders.
Correct Answer: C
Rationale: Difficulty breathing indicates a potential airway obstruction, possibly due to postoperative swelling, which is a priority. Stridor and difficulty swallowing are also concerns but maintaining an airway takes precedence. Weak pedal pulses and inability to shrug shoulders are less urgent.
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this work plan care?
- A. Encourage the client to stretch the back by reaching toward the toes.
- B. Massage the affected area with ice twice a day.
- C. Apply a heating pad for 20 minutes at least four times daily.
- D. Advise the client to avoid warm baths or showers.
Correct Answer: C
Rationale: Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
- A. Peripheral edema
- B. Black and tarry stools
- C. Bradycardia
- D. Nausea and vomiting
Correct Answer: C
Rationale: Fingolimod (Gilenya) can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not typical adverse effects of this medication.
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
- A. Participate in an exercise program to strengthen muscles.
- B. Purchase a mattress that allows you to adjust the firmness.
- C. Wear flat instead of high-heeled shoes to work each day.
- D. Keep your weight within 20% of your ideal body weight.
Correct Answer: A
Rationale: Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?
- A. Screen for metal implants or devices.
- B. Implement nothing by mouth (NPO) status for 8 hours.
- C. Administer a sedative to reduce anxiety.
- D. Ensure the client has an empty bladder.
Correct Answer: A
Rationale: Screening for metal implants or devices is critical before an MRI to prevent harm due to magnetic fields. NPO status, sedation, and bladder emptying are not typically required unless specified.