Nokea
The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings indicates autonomic dysreflexia?
- A. Bradycardia and hypertension.
- B. Tachycardia and hypotension.
- C. Fever and chills.
- D. Hypoxia and cyanosis.
Correct Answer: A
Rationale: Autonomic dysreflexia presents with bradycardia and hypertension due to unopposed sympathetic stimulation below the injury level.
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The nurse is assessing a client with a suspected acute pancreatitis. Which of the following laboratory findings is most indicative of this condition?
- A. Elevated amylase and lipase.
- B. Decreased white blood cell count.
- C. Elevated hemoglobin.
- D. Decreased blood glucose.
Correct Answer: A
Rationale: Elevated amylase and lipase are hallmark laboratory findings in acute pancreatitis due to pancreatic enzyme release.
During an appointment with the nurse, a client says, 'I need to find the good,' the nurse responds, 'Oh, don't feel that way. We're making progress in these sessions.' The nurse's statement demonstrates a failure to do which of the following?
- A. Look for meaning in what the client says.
- B. Explain to the client why he may think as he does.
- C. Add to the strength of the client's support system.
- D. Give the client credit for solving his own problems.
Correct Answer: A
Rationale: The nurse's response dismisses the client's statement, failing to explore its underlying meaning, which is essential for therapeutic communication.
Which of the following should be a priority nursing diagnosis for a client who has had a total laryngectomy?
- A. Risk for impaired skin integrity.
- B. Excess fluid volume.
- C. Ineffective thermoregulation.
- D. Impaired verbal communication.
Correct Answer: D
Rationale: Impaired verbal communication is the priority after a total laryngectomy due to the loss of vocal cords, affecting communication ability.
A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order should the nurse take the following actions?
- A. Loosen clothing around the client's neck.
- B. Turn the client on his or her side.
- C. Clear the area around the client.
- D. Suction the airway.
Correct Answer: C,B,A,D
Rationale: First, clear the area to prevent injury, turn the client on their side to maintain airway patency, loosen clothing to ease breathing, and suction if needed to clear secretions.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. The nurse should monitor the client for which of the following complications?
- A. Hypercapnia.
- B. Hypotension.
- C. Pulmonary edema.
- D. Metabolic alkalosis.
Correct Answer: A
Rationale: Clients with COPD are at risk for hypercapnia (elevated CO2 levels) during pneumonia due to impaired gas exchange, which can worsen respiratory distress.