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 hospice care includes bereavement support for the family for up to a year after the client's death.
B is incorrect because the hospice nurse does not administer pain medication, but rather teaches the family how to manage the client's pain at home.
C is incorrect because respite care is one of the services that hospice provides to allow the family to take a break from caregiving.
D is incorrect because hospice care does not aim to prolong life, but rather to provide comfort and quality of life for the client and the family.
Correct Answer is B
Explanation
A is incorrect because documenting client tasks upon completion is an appropriate action by the newly licensed nurse that demonstrates accuracy and timeliness of documentation.
B is correct because starting a task then determining what supplies are needed is an inappropriate action by the newly licensed nurse that indicates poor planning and organization skills.
C is incorrect because completing a client assessment while infusing an IV antibiotic over 30 min is an appropriate action by the newly licensed nurse that demonstrates efficient use of time and multitasking ability.
D is incorrect because returning to the nurses' station after completing several tasks in the same location is an appropriate action by the newly licensed nurse that demonstrates effective prioritization and delegation skills.
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