A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?
A measure the calves for symmetry
B palpate the bladder
C Place a pillow between the knees and ankles
D Check the gag reflex
The Correct Answer is C
Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.
Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.
Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.
Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A Rationale: Hypertension is not a sign of neurogenic shock, but rather of autonomic dysreflexia, a life-threatening condition that can occur in patients with spinal cord injury above T6.
Choice B Rationale: Rapidly elevating temperature is also a sign of autonomic dysreflexia, not neurogenic shock. Neurogenic shock can cause hypothermia due to impaired thermoregulation.
Choice C Rationale: Bradycardia is a sign of neurogenic shock due to the loss of sympathetic stimulation to the heart, which normally increases the heart rate and contractility.
Choice D Rationale: Fixed and dilated pupils are a sign of brain death, not neurogenic shock. Neurogenic shock can cause miosis (constriction of the pupils) due to unopposed parasympathetic stimulation.
Choice E Rationale: Hypotension is a sign of neurogenic shock due to the vasodilation and decreased venous return caused by the loss of sympathetic tone.
Correct Answer is D
Explanation
Choice A Rationale: Eating only cold foods is not a common recommendation for preventing trigeminal neuralgia flare-ups.
Choice B Rationale: Massaging the affected side multiple times a day is not typically recommended and may exacerbate symptoms.
Choice C Rationale: Applying heat or cold to alleviate symptoms can vary depending on individual preferences and is not a primary preventive measure for triggering an acute onset.
Choice D Rationale: Using a soft bristle toothbrush and warmed mouthwash is a recommended preventive measure to avoid triggering acute episodes of trigeminal neuralgia. It helps reduce irritation to the affected nerves.
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