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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. Being suspicious of others is more characteristic of paranoid personality disorder.
B. Incorrect. Ritualistic behavior is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Preoccupation with aging and a fear of losing their physical attractiveness or power is a common trait in individuals with narcissistic personality disorder.
D. Incorrect. Exhibiting separation anxiety is not a defining characteristic of narcissistic personality disorder.

A. Initiate seclusion protocol. B. Tell the client, "You seem to be very upset." C. Use a face shield with a mask when providing care to the client. D. Engage the panic alarm.

Correct Answer is B

Explanation

A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.

B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.

C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.

D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Correct Answer is B

Explanation

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? (Select all that apply.)

A nurse in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

A nurse is caring for a client who has been admitted to the antepartum unit. Exhibits Complete the following sentence by using the list of options. The nurse should recognize the client is experiencing dropdown due to dropdown