Nokea
Which intervention is most effective for managing autonomic dysreflexia in a client with a spinal cord injury?
- A. Elevate the head of the bed.
- B. Administer a bronchodilator.
- C. Apply a warm compress to the abdomen.
- D. Insert a urinary catheter immediately.
Correct Answer: D
Rationale: Autonomic dysreflexia is often triggered by bladder distension; immediate catheterization relieves the stimulus.
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Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
- A. A 55-year-old African American male.
- B. An 84-year-old Japanese female.
- C. A 67-year-old Caucasian male.
- D. A 39-year-old pregnant female.
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the NA to help the client with meals knowing that this problem may result in which client response?
- A. Tendency to fall to the contralateral side
- B. Eating food on only half of the plate
- C. Using the silverware inappropriately
- D. Choking when swallowing any liquids
Correct Answer: B
Rationale: Tendency to fall to the contralateral side would be a concern if the client were weak or paralyzed. Homonymous hemianopia (hemianopsia) is a visual field abnormality that results in blindness in half of the visual field in the same side of both eyes. It results from damage to the optic tract or occipital lobe. Using the silverware inappropriately is a concern if the client has agnosia. Choking when swallowing any liquids is a concern if the client has dysphagia.
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.
The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply.
- A. Assess for deep vein thrombosis.
- B. Administer intravenous anticoagulant.
- C. Monitor intake and output strictly.
- D. Apply warm compresses to the eyes.
- E. Perform passive range-of-motion exercises.
Correct Answer: A,C,E
Rationale: Assessing DVT (A), monitoring intake/output (C), and passive ROM (E) prevent complications. Anticoagulants (B) increase bleeding risk, and warm compresses (D) are not indicated.
To correctly perform the eye irrigation, the nurse instills the eye irrigant in which direction?
- A. In the lower conjunctiva toward the corneal surface
- B. From the outer canthus of the eye to the inner canthus
- C. From the nasal corner of the eye toward the temple
- D. From the margins of the eyelashes to the folds of the lids
Correct Answer: C
Rationale: Instilling irrigant from the inner canthus to the outer canthus follows the natural flow of tears, preventing contamination.