Nokea
The nurse is caring for a client with a history of spinal cord injury.
- A. Which intervention is most effective for preventing autonomic dysreflexia in a client with a spinal cord injury?
- B. Monitor blood pressure regularly.
- C. Administer analgesics for pain.
- D. Keep the bladder empty.
- E. Encourage a low-fiber diet.
Correct Answer: C
Rationale: Keeping the bladder empty prevents distension, a common trigger for autonomic dysreflexia, a life-threatening hypertensive crisis in spinal cord injury. Blood pressure monitoring detects it, analgesics are irrelevant, and high-fiber diets prevent constipation.
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Which assessment is most essential before administering digoxin to an adult?
- A. Ask the client if he has chest pain.
- B. Take an apical pulse.
- C. Take the client's blood pressure.
- D. Ask the client if he is short of breath.
Correct Answer: B
Rationale: Taking an apical pulse ensures the heart rate is above 60 bpm, as digoxin can cause bradycardia, a critical safety check.
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.
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)
A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
- A. Assist the client with activities of daily living
- B. Monitor the clients physical safety
- C. Evaluate for basic comfort needs
- D. Document mental status and muscle strength
Correct Answer: A
Rationale: Assist the client with activities of daily living. The person to whom the activity is delegated must be capable of performing it. The UAP is capable of assisting clients with basic needs.
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
- A. To increase oxygen to the brain
- B. To dilate the cerebral blood volume
- C. To increase the cerebral blood volume
- D. To promote cerebral vasoconstriction and decrease cerebral blood flow
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.