Nokea
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
- A. Respiratory depression
- B. Autonomic dysreflexia
- C. Pressure ulcers
- D. Deep vein thrombosis
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.
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A client with a history of heart failure is receiving Carvedilol (Coreg). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Tachycardia
- D. Weight gain
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause hypotension due to vasodilation and reduced heart rate. Hyperglycemia, tachycardia, and weight gain are not primary concerns.
The nurse is teaching a client with hypertension about dietary modifications. Which food choice indicates a need for further teaching?
- A. Fresh apple
- B. Baked chicken
- C. Canned soup
- D. Steamed broccoli
Correct Answer: C
Rationale: Canned soup is high in sodium, which exacerbates hypertension, indicating a need for further teaching. Apple (A), chicken (B), and broccoli (D) are low-sodium and appropriate.
A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to 'feel kind of shaky.' Based on the information given above, nursing care goals for this client will initially focus on:
- A. Self-concept problems
- B. Interpersonal issues
- C. Ineffective coping skills
- D. Physiological stabilization
Correct Answer: D
Rationale: Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.
The nurse is teaching a client with a history of osteoporosis about fall prevention. The nurse should tell the client to:
- A. Remove clutter from walkways
- B. Use high-heeled shoes
- C. Avoid handrails
- D. Keep rooms dimly lit
Correct Answer: A
Rationale: Removing clutter prevents falls in osteoporosis, reducing fracture risk.
The nurse is caring for a client with a history of Addison’s disease. The nurse should expect the client to have:
- A. Hypotension
- B. Hypertension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Addison’s disease causes adrenal insufficiency, reducing cortisol and aldosterone, leading to hypotension due to fluid and sodium loss.