A nurse is caring for a client who has a spinal cord injury.
Nurses' Notes 0600:
Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.
1000:
Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.
Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions
Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
Administer nifedipine
Assess blood pressure every 15 min.
Perform suctioning.
Assess for urinary retention.
Place client in supine position.
Withhold pain medication for headache until other manifestations resolve.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Anticipated actions for the client include:
- A. Administer nifedipine.
- B. Assess blood pressure every 15 minutes.
- D. Assess for urinary retention.
Contraindicated actions for the client include:
- C. Perform suctioning (since there is no indication or information suggesting the need for suctioning).
- E. Place client in supine position (as it might worsen the symptoms).
- F. Withhold pain medication for headache until other manifestations resolve (it's important to address the headache promptly, especially if acetaminophen is prescribed for pain relief).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.
Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.
Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.
Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.
Correct Answer is A
Explanation
A. Correct. Donepezil is a medication used to treat Alzheimer's disease and is expected to improve cognitive function, including short-term memory.
B. Incorrect. Donepezil is not typically associated with changes in food intake.
C. Incorrect. While improved functional ability is a goal of treatment, performing ADLs independently might not be solely indicative of donepezil's effectiveness.
D. Incorrect. Donepezil is primarily focused on improving cognitive function rather than mood enhancement.
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