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. The client is at risk for developing ______ due to _______. Nurses' Notes 07.00: Client alert and oriented x 3. Denies pain. Client unable to move lower extremities. Urinary catheter draining clear amber urine. Client turned to right. 08.05: Client alert and oriented x 3. Denies pain. Client unable to move lower extremities. Urinary catheter draining clear amber urine. Client turned to left. 09.10: Client reporting headache as a 9 on 0 to 10 pain scale. Client is diaphoretic with flushed skin. Alert and oriented x 3. Client appears agitated with labored breathing. Urinary output diminished Medication Administration Record 07.00: Enoxaparin 40 mg subcutaneous daily 08.45: Dexamethasone 4 mg IV every 12 hr Lactated Ringers solution IV 150 mL/hr Gabapentin 300 mg PO twice daily I&O 07.00: Input: 150 mL Output: 60 mL 08.00: Input 150 mL Output 40 mL 09.00: Input 180 mL Output 10 mL
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 A
Explanation
A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.
Correct Answer is B
Explanation
A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities.
When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
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