Nokea
Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?
- A. sudden onset of headache
- B. flushed face
- C. hypotension
- D. nasal congestion
Correct Answer: C
Rationale: Hypotension is not indicative of autonomic dysreflexia; rather, hypertension is a sign of autonomic dysreflexia.
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The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?
- A. Nutrition
- B. Elimination
- C. Activity
- D. Safety
Correct Answer: D
Rationale: Safety. A depressed client is at acute risk for self-destructive behavior, making safety the priority.
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of the incentive spirometer.
- B. Administer pain medication as needed.
- C. Apply a continuous passive motion (CPM) machine.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Applying the CPM machine prevents stiffness and promotes mobility post-knee replacement. Options A, B, and D are secondary.
The client is scheduled for a myelogram today. The permit has been signed. The client tells the nurse that she has changed her mind and does not want to have the procedure. What should the nurse do?
- A. Tell the client that once permission has been given, the procedure has to be done
- B. Tell the client that the physician will be very upset if she does not have it done
- C. Suggest to the client that it is in her best interests to have the procedure as scheduled
- D. Understand that the client has the right to change her mind about procedures
Correct Answer: D
Rationale: Clients have the right to withdraw consent at any time, respecting autonomy. Coercion or suggesting physician displeasure is unethical.
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
- A. Monitor for hyperkalemia
- B. Place in protective isolation
- C. Precautions with position changes
- D. Administer diuretics as ordered
Correct Answer: C
Rationale: Precautions with position changes. Multiple myeloma causes osteoporosis, increasing the risk of pathological fractures, necessitating careful positioning.
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.