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The nurse is caring for a client with a T4 spinal cord injury. Which finding indicates that the client is experiencing neurogenic shock?
- A. Blood pressure 82/40 mm Hg, pulse 48 beats/min
- B. Blood pressure 150/90 mm Hg, pulse 110 beats/min
- C. Blood pressure 110/70 mm Hg, pulse 88 beats/min
- D. Blood pressure 130/80 mm Hg, pulse 62 beats/min
Correct Answer: A
Rationale: Neurogenic shock in T4 SCI features hypotension and bradycardia (A, 82/40, 48 bpm) from sympathetic loss. Hypertension/tachycardia (B) suggests dysreflexia. C and D are normalish. A is correct. Rationale: Loss of vasomotor tone below T4 causes vasodilation and unopposed vagal activity, per SCI pathophysiology, requiring fluids and atropine.
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Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A. A ham and Swiss cheese sandwich on whole wheat bread
- B. Mashed potatoes and broiled chicken
- C. A tossed salad with oil and vinegar and olives
- D. Chicken bouillon
Correct Answer: B
Rationale: Mashed potatoes and broiled chicken are low in sodium, unlike ham, olives, or bouillon.
Mr. Gary's insurance paid for his hospital stay. This is an example of?
- A. Health care financing
- B. Cost-effectiveness
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Insurance paying is health care financing (A) funding services, per definition. Cost-effectiveness (B) value, policy (C) rules, education (D) teaching not funding-specific. A fits Mr. Gary's care support, making it correct.
These are data that are monitored by using graphic charts or graphs that indicated the progression or fluctuation of client's Temperature and Blood pressure.
- A. Progress notes
- B. Kardex
- C. Flow chart
- D. Flow sheet
Correct Answer: D
Rationale: Flow sheets (D) use graphs to track temperature and BP fluctuations, per charting norms. Progress notes (A) narrate, Kardex (B) summarizes, flow charts (C) diagram processes. D matches graphical monitoring, making it correct.
A theory is a set of concepts, definitions, relationships and assumptions that:
- A. Explain a phenomenon
- B. Formulate legislation
- C. Measure nursing functions
- D. Reflect the domain of nursing practice
Correct Answer: A
Rationale: A theory e.g., Henderson's uses concepts (e.g., breathing), definitions (clarifying terms), relationships (how needs interact), and assumptions (e.g., patients seek independence) to explain phenomena like recovery. This informs nursing actions e.g., why positioning aids breathing. Formulating legislation is policy, not theory's role indirectly influenced. Measuring functions suits research, not theory's explanatory purpose. Reflecting the domain describes scope, not function explanation is active. Theories explain health-related events, providing nurses frameworks to understand and address client needs, making this the precise definition.
You are caring for a client who has just returned from surgery and has received intravenous morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at which of the following times?
- A. in 20 to 30 minutes
- B. in one hour
- C. in two hours
- D. in 3 to 4 hours
Correct Answer: A
Rationale: Post-morphine pain assessment at 20-30 minutes evaluates peak effect, critical post-surgery. Later checks miss this window. Nurses time this for efficacy.