A nurse is administering a cold application to a client. Which of the following manifestations indicates the need to discontinue the application due to a systemic response by the client?
Reduced blood viscosity
Numbness
Hypotension
Shivering
The Correct Answer is C
A. Reduced blood viscosity: This is a local effect of cold, not a harmful systemic response.
B. Numbness: Numbness can be an expected local response but is not necessarily systemic.
C. Hypotension: This indicates a systemic vasovagal response to cold and signals the need to stop the therapy.
D. Shivering: Shivering is a response to feeling cold but is less concerning than hypotension, which may compromise perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for correct answers:
a) Apply soft wrist restraints with assistance:
The nurse has already received a prescription from the provider for restraints due to the client actively attempting to remove medical devices. This makes the restraint medically justified and legally authorized. The restraints should be applied safely and with assistance to prevent injury during application.
c) Document the restraint application, reason, and patient response in the record:
Documentation is a legal and professional responsibility. It ensures the rationale, time, condition, interventions attempted before restraints, and client response are recorded clearly.
Rationale for incorrect answers:
b) Administer pain medication for agitation:
No indication in the note suggests pain as the cause of agitation. Medication without cause or order for agitation is inappropriate.
c) Notify the family of the restraint application:
While notifying the family is appropriate and often done, it is not the first or immediate priority once the restraint order is in place and the client is at risk of self-harm.
a) Notify charge nurse and ask for sitter assignment:
This is a helpful support measure, but after applying the restraints and documenting the care. It does not take precedence over immediate client safety and legal documentation.
b) Remove the catheter and IV to prevent further injury:
This would violate the standard of care unless ordered by the provider. The correct action is to prevent removal by using restraints safely and legally.
Correct Answer is A
Explanation
A. Lower the head of the bed: This facilitates a horizontal transfer by making the bed and stretcher levels even, reducing strain during the move.
B. Place the bed in its lowest position: The bed should be adjusted to the same height as the stretcher for a smoother transfer.
C. Unlock the wheels on the bed: The wheels must be locked to prevent movement and injury.
D. Have two caregivers at the side of the bed: While help is needed, one caregiver on each side and possibly one at the head or foot is preferred depending on the client’s condition.
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