A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.
The patient complains of feeling dizzy and is diaphoretic.
What would be the priority nursing action?

Establish IV access and bolus 250 mL of normal saline.

Reschedule the therapy session for later in the day.

Lower the head of the bed and obtain vital signs.

Assess for bladder distention and perform digital disimpaction.

Answer and Explanation

The Correct Answer is C

Choice A rationale

IV fluid bolus may address hypotension but is not the first priority. Symptoms of dizziness and diaphoresis in a spinal cord injury patient suggest autonomic dysreflexia or orthostatic hypotension requiring positional changes first.

Choice B rationale

Rescheduling therapy does not address the acute symptoms the patient is experiencing. Immediate action to manage dizziness and diaphoresis, such as altering body position, is required to stabilize the patient.

Choice C rationale

Lowering the head of the bed counters orthostatic hypotension, a common issue in spinal cord injury patients. Obtaining vital signs identifies the underlying cause and guides further interventions.

Choice D rationale

Bladder distention can trigger autonomic dysreflexia, but without evidence of urinary retention, prioritizing positional adjustments is more urgent to alleviate symptoms of dizziness and stabilize hemodynamics.

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Correct Answer is B

Explanation

Choice A rationale

Bipolar disorder is an approved indication for valproic acid use. It helps stabilize mood swings, particularly mania, making it a suitable treatment rather than a contraindication.

Choice B rationale

Pre-existing liver disease contraindicates valproic acid because it increases the risk of hepatic toxicity and liver failure. Liver function must be closely monitored in all patients receiving this drug.

Choice C rationale

Asthma is not affected by valproic acid use as the drug targets neurological pathways and does not impact respiratory or bronchial systems significantly.

Choice D rationale

Valproic acid is used to treat migraines and seizures. It prevents the occurrence of severe headaches through stabilization of neuronal activity, making this an appropriate rather than contraindicated use. .

A. Oxygen at 6 liters per minute via nasal cannula. B. Ipratropium via metered dose inhaler. C. Propranolol by oral administration. D. An organic herbal supplement.

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.

Choice B rationale

Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.

Choice C rationale

Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.

Choice D rationale

Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.

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A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.The patient complains of feeling dizzy and is diaphoretic.What would be the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that an important contraindication for valproic acid use is:

Correct Answer is B

Explanation

A client has a past medical history of coronary artery disease and emphysema.The nurse knows which agent is safest to give?

Correct Answer is B

Explanation

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A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.
The patient complains of feeling dizzy and is diaphoretic.
What would be the priority nursing action?