A nurse is caring for a client.

Exhibits

Click to specify if the client statements indicate understanding or no understanding.

"I will have to stop watching television while I eat."

"I won't be able to eat nuts anymore."

"My food will have to be the consistency of pudding."

"I can have cream soups on this diet."

"I will look up at the ceiling when I swallow."

"I shouldn't drink liquids while I have food in my mouth."

Answer and Explanation

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

"I will have to stop watching television while I eat." Understanding: Multitasking while eating can increase the risk of choking, so focusing on the meal is important.

"I won't be able to eat nuts anymore." Understanding: Nuts are not appropriate for a Level 3 dysphagia diet due to their texture, which can be a choking hazard.

"My food will have to be the consistency of pudding." Understanding: A Level 3 dysphagia diet involves foods with a pudding-like consistency to minimize choking risk.

"I can have cream soups on this diet." No Understanding: Cream soups are typically too thin for a Level 3 dysphagia diet, which requires thicker consistencies.

"I will look up at the ceiling when I swallow." No Understanding: The correct practice is to keep the head level or slightly tilted forward, not to look up at the ceiling.

"I shouldn't drink liquids while I have food in my mouth." Understanding: Drinking liquids while chewing food can increase the risk of aspiration or choking.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Placing the client in a supine position can increase ICP. The head of the bed should be elevated 30-45 degrees to promote venous drainage from the head.
B. Using log rolling to reposition the client helps to maintain spinal alignment and prevent increases in ICP.
C. A warming blanket is not typically necessary unless the client is hypothermic; it does not directly affect ICP management.
D. Instructing the client to cough and deep breathe can increase ICP and should be avoided in clients with elevated ICP.

A. The client states having nasal congestion. B. The client states having a severe headache. C. The client's blood pressure becomes elevated. D. The client's bladder becomes distended.

Correct Answer is D

Explanation

A. Nasal congestion is not a primary sign of autonomic dysreflexia, though it can be a symptom of other conditions.

B. A severe headache can be a symptom of autonomic dysreflexia but is not the sole indicator of the condition.

C. Elevated blood pressure can be a result of autonomic dysreflexia but is not necessarily an indication of risk without other symptoms.

D. A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.

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A nurse is caring for a client. Exhibits Click to specify if the client statements indicate understanding or no understanding.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is D

Explanation

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

A nurse in the emergency department is admitting a client. Exhibits For each of the following findings in the client's medical record, click to specify if they are consistent with angina or a myocardial infarction (MI). Each finding may support more than one disease process.

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?

A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

A nurse is caring for a client.

Exhibits

Click to specify if the client statements indicate understanding or no understanding.