A nurse is caring for a client on a medical-surgical unit

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing
dropdown
as evidenced by the client's
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.

Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.

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Correct Answer is ["B","D"]

Explanation

A. A turning schedule every 4 hours is insufficient; repositioning should ideally be done every 2 hours to prevent pressure injuries.

B. Reducing skin exposure to moisture helps maintain skin integrity, especially in areas prone to breakdown due to moisture accumulation.

C. Powder is not recommended as it can lead to skin irritation and potential breakdown.

D. Elevating heels with pillows relieves pressure on areas that are susceptible to pressure injuries in immobilized clients.

E. Massaging erythematous bony prominences can damage capillaries and increase the risk of pressure injury formation.

A. Buck's extension traction will relieve muscle spasms. B. Buck's extension traction will allow supported movement of the extremity. C. Buck's extension traction will maintain alignment of the pins. D. Buck's extension traction will reduce the fracture.

Correct Answer is A

Explanation

A. Buck's traction is commonly used to relieve muscle spasms and provide pain relief before surgical repair.

B. It does not allow movement of the extremity but rather limits movement to reduce pain.

C. Buck's traction does not involve pins, so alignment of pins is not relevant.

D. It does not reduce fractures but helps to maintain alignment and comfort until surgery.

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A nurse is caring for a client on a medical-surgical unit Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown as evidenced by the client's dropdown .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?

Correct Answer is ["B","D"]

Explanation

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Correct Answer is A

Explanation

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A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following statements indicates an understanding of the teaching? (Select All that Apply.)

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A nurse is caring for a client on a medical-surgical unit Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown as evidenced by the client's dropdown .

A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

A nurse is caring for a client on a medical-surgical unit

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing
dropdown
as evidenced by the client's
dropdown
.