Nokea
The nurse is taking care of a client with a spinal cord injury. The extent of the client’s injury is shown below. Which of the following findings is expected when assessing this client?
- A. Inability to move his arms
- B. Loss of sensation in his hands and fingers.
- C. Dysfunction of bowel and bladder.
- D. Difficulty breathing.
Correct Answer: C
Rationale: This client has a spinal cord injury of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia.
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A client with acute renal failure has edema. The nurse should:
- A. Elevate the legs.
- B. Restrict fluids.
- C. Administer a diuretic.
- D. Increase sodium intake.
Correct Answer: B
Rationale: Fluid restriction helps manage edema in acute renal failure.
The nurse should monitor the client with Cushing's disease for which of the following?
- A. Postprandial hypoglycemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Decreased urine calcium level.
Correct Answer: B
Rationale: Hypokalemia is common in Cushing's disease due to aldosterone excess, causing potassium loss.
A client is admitted from the emergency department after falling down a flight of stairs at home. Her vital signs are stable and her history states that she had a gastric stapling 2 years ago and takes neomycin for acne. The client jokes about how she is clumsy lately and trips over things. The nurse should ask the client which of the following questions? Select all that apply.
- A. Are you experiencing numbness in your extremities?'
- B. How much vitamin B12 are you getting?'
- C. Are you feeling depressed?'
- D. Do you feel safe at home?'
- E. Are you getting sufficient iron in your diet?'
Correct Answer: A,B,D
Rationale: Gastric stapling can impair vitamin B12 absorption, and neomycin may further reduce B12 levels by altering gut flora. The client's clumsiness and falls suggest possible B12 deficiency neuropathy, warranting questions about numbness and B12 intake. Asking about safety at home is crucial to assess for environmental or abuse-related causes of falls. Depression and iron intake are less directly related to the symptoms described.
What is the nurse's best action for a client with a migraine headache?
- A. Administer oxygen.
- B. Provide a quiet, dark environment.
- C. Encourage fluid restriction.
- D. Apply a warm compress.
Correct Answer: B
Rationale: A quiet, dark environment reduces stimuli that exacerbate migraine symptoms.
The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
- A. Cerebrovascular accidents (CVAs).
- B. Liver disease.
- C. Myocardial infarction.
- D. Pulmonary disease.
Correct Answer: A,C
Rationale: Hypertension increases the risk of cerebrovascular accidents (A) and myocardial infarction (C), as it damages blood vessels, leading to stroke or heart attack.