A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take?

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Encourage the client to cough.

Initiate seizure precautions.

Elevate the head of the bed.

Keep the client's head in a midline position.

Decrease oxygen to 1.5 L/min via nasal cannula.

Assist the client to the bathroom.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Rationale

Interpretation of Actions:

Encourage the client to cough:
- Nonessential
  Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
Initiate seizure precautions:
- Anticipated
  Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
Elevate the head of the bed:
- Anticipated
  Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
Keep the client's head in a midline position:
- Anticipated
  Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
Decrease oxygen to 1.5 L/min via nasal cannula:
- Contraindicated
  Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
Assist the client to the bathroom:
- Contraindicated
  Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Decreased coagulation is not a characteristic finding in nephrotic syndrome. In fact, nephrotic syndrome can increase the risk of thromboembolic events due to the loss of anticoagulants in the urine.

B. Decreased serum lipid levels are not expected in nephrotic syndrome. In fact, nephrotic syndrome is often associated with increased serum lipid levels (hyperlipidemia), as the liver increases production of lipoproteins in response to protein loss.

C. Proteinuria is a hallmark of nephrotic syndrome. The condition is characterized by excessive protein loss in the urine, which leads to hypoalbuminemia and edema.

D. Hyperalbuminemia is not expected in nephrotic syndrome. The condition typically leads to hypoalbuminemia due to the loss of albumin in the urine.

A. Raise the head of the client's bed to a 90° angle. B. Use moisturizing lotion while massaging the client's bony prominences. C. Place pillows between the client's knees when in a side-lying position. D. Instruct the client to sit on a rubber ring when seated in a chair.

Correct Answer is C

Explanation

A. Raising the head of the bed to a 90° angle is not recommended for clients with hemiplegia as it can cause discomfort and increase the risk of pressure ulcers. A semi-Fowler's position (30° to 45°) is usually more appropriate.

B. While using moisturizing lotion on bony prominences is important to prevent skin breakdown, it is not specific to the management of hemiplegia. The focus for hemiplegia is more on positioning, mobility, and preventing complications like contractures.

C. Placing pillows between the client's knees when in a side-lying position is an appropriate intervention for a client with hemiplegia. This helps maintain proper alignment of the limbs, prevents pressure sores, and reduces the risk of contractures in the affected side.

D. Instructing the client to sit on a rubber ring is generally not recommended for clients with hemiplegia, as it may not provide adequate support and can lead to improper posture or skin breakdown. Proper seating supports and positioning should be emphasized instead.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

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