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 D
Explanation
Choice A reason
"I can use natural-skin condoms to prevent sexually transmitted infections." This statement is incorrect. Natural-skin or lambskin condoms are not recommended for preventing sexually transmitted infections (STIs). They may provide some protection against pregnancy but do not effectively protect against STIs. Clients should use latex or polyurethane condoms to reduce the risk of STIs.
Choice B reason
"I can use petroleum jelly as a lubricant with the condom." This statement is also incorrect. Petroleum jelly (Vaseline) and other oil-based lubricants can damage latex condoms, leading to a higher risk of breakage or failure. Clients should use water-based or silicone-based lubricants with latex or polyurethane condoms.
Choice C reason:
"I can re-use the condom one time after initial use." This statement is incorrect. Condoms are designed for single-use only. Reusing a condom increases the risk of breakage, failure, and the transmission of STIs or unwanted pregnancy. Clients should always use a new condom for each sexual act.
Choice D reason:
"I can store the condoms in the drawer of my nightstand." This statement is correct because it indicates that the client understands the proper storage of condoms. Storing condoms in a cool, dry place, such as a drawer or a condom case, helps protect them from damage or deterioration, ensuring they remain effective when needed.
Correct Answer is B
Explanation
A: Incorrect. Decreased blood pressure is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be monitored and reported.
B: Correct. Decreased hallucinations are an indication of chlorpromazine effectiveness, as this medication is an antipsychotic that blocks dopamine receptors in the brain and reduces psychotic symptoms such as hallucinations, delusions, and paranoia.
C: Incorrect. Decreased cholesterol is not an indication of chlorpromazine effectiveness, but rather a potential benefit that may occur due to its effect on lipid metabolism.
D: Incorrect. Decreased esophageal reflux is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be avoided by taking the medication with food or water and avoiding lying down after administration.
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