Nokea
The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
- A. Assist the client to develop a daily bowel routine to prevent constipation.
- B. Teach the client to manage emotional stressors by using mental imaging.
- C. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.
- D. Administer dexamethasone orally per the primary health care provider's prescription.
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.
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The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
- A. Determine the need to increase the oxygen.
- B. Reassure the client that there is no need to worry.
- C. Conduct further assessment of the client's respiratory status.
- D. Call emergency services to take the client to the emergency department.
Correct Answer: C
Rationale: With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is 'no need to worry' is inappropriate. Calling emergency services is a premature action.
An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client's neurovascular status? Select all that apply.
- A. Pain level
- B. Urinary output
- C. Ability to move all extremities
- D. Capillary refill in all extremities
- E. Ability to flex and extend the feet
- F. Ability to detect sensations in all extremities
Correct Answer: C,D,E,F
Rationale: When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks, including circulation, sensation, and motion, should be done at least every 2 hours. Level of pain and urinary output are important postoperative assessments, but neurovascular status is more important.
To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food?
- A. Bowel sounds
- B. Chewing ability
- C. Current appetite
- D. Food preferences
Correct Answer: B
Rationale: The nurse needs to assess the client's chewing ability before advancing a client from liquid to solid food. It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing because of the risk of aspiration. Bowel sounds should be present before introducing any diet, including liquids. Appetite will affect the amount of food eaten, but not the type of diet prescribed. Food preferences should be ascertained on admission assessment.
The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply.
- A. A client with a history of previous infections
- B. A client who has given birth to a set of twins
- C. A client who had numerous vaginal examinations
- D. A client who has experienced three previous miscarriages
- E. A client who underwent a vaginal delivery of the newborn
- F. A client who experienced prolonged rupture of the membranes
Correct Answer: A,C,F
Rationale: Risk factors associated with puerperal infection include a history of previous infections, excessive number of vaginal examinations, cesarean births, prolonged rupture of the membranes, prolonged labor, trauma, and retained placental fragments. A vaginal delivery, a history of miscarriages, and the delivery of twins are not considered as risk factors for developing a puerperal infection.
A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially?
- A. Where and when the medication was ingested
- B. The name and amount of ingested medication
- C. If the client continues to have suicidal ideations
- D. If there is a history of previous suicidal attempts
Correct Answer: B
Rationale: In an emergency, lifesaving facts are obtained first. The name of and the amount of medication ingested is of utmost importance in treating this potentially life-threatening situation. The remaining data can be assessed once the client's physical condition is stabilized.