A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.
Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Mild pain in the hip region can be caused by various musculoskeletal issues, such as muscle strains, bursitis, or even referred pain from other areas. It is not a characteristic symptom of scoliosis.
Choice B reason
Scoliosis is characterized by an abnormal sideways curvature of the spine, which can cause uneven shoulders and pelvic heights. As the spine curves abnormally, it can lead to asymmetry in the shoulders and hips, which are noticeable during physical examination. This asymmetry is a key clinical sign that suggests the presence of scoliosis.
Choice C reason:
Limited range of motion (ROM) of the hips is more likely related to hip joint issues or musculoskeletal conditions affecting the hips, not specifically scoliosis.
Choice D reason:
Exaggerated curvature of the sacrum may indicate other spinal abnormalities or conditions affecting the lower back, but it is not typically associated with scoliosis, which primarily affects the curvature of the spine higher up in the thoracic or lumbar regions.
Correct Answer is A
Explanation
- Cocaine is a powerfully addictive stimulant drug that increases the levels of dopamine in the brain, which is a chemical messenger related to movement, pleasure, and motivation.
- Cocaine's effects appear almost immediately and last for a few minutes to an hour, depending on the method of use. Some of the short-term effects of cocaine include extreme happiness and energy, mental alertness, hypersensitivity to sight, sound, and touch, and irritability.
- An elevated energy level is one of the most common and noticeable effects of cocaine use, as cocaine stimulates the central nervous system and makes the user feel more alert, active, and confident¹². This effect may also lead to increased physical activity, talkativeness, or aggression.
Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because a powerful craving for more cocaine is not a behavior that can be observed by others, but rather an internal feeling that the user may experience due to the addictive nature of the drug.
Option C is incorrect because high self-esteem is not a typical effect of cocaine use, as cocaine may cause paranoia or anxiety in some users.
Option D is incorrect because euphoria is not a behavior that can be observed by others, but rather an emotional state that the user may feel due to the increased dopamine levels in the brain
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