After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

A Sit the client at a 90 degree angle

B Administer 2000 liters of fluid

C Apply compression socks

D Maintain blood pressure exactly at 110/80

Answer and Explanation

The Correct Answer is A

Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.

Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.

Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.

Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.

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Correct Answer is D

Explanation

Choice A Rationale: Leakage is not typically associated with upper motor neuron deficits related to a spinal cord injury.

Choice B Rationale: Anuria (absence of urine production) is not a common manifestation of upper motor neuron deficits in this context.

Choice C Rationale: A flaccid bladder and an inability to voluntarily void are more characteristic of lower motor neuron deficits. Upper motor neuron deficits often lead to spasticity and involuntary voiding.

Choice D Rationale: Spasticity and involuntary voiding are common manifestations of upper motor neuron deficits related to spinal cord injury. This is due to the loss of inhibitory control over reflexes, including the micturition reflex.

A. Simple puzzles B. Board games C. Dangling ribbons or a mobile D. Drawing with crayons

Correct Answer is A

Explanation

Choice A Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.

Choice B Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.

Choice C Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.

Choice D Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.

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After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

Correct Answer is D

Explanation

A client diagnosed with severe Alzheimer's has been admitted to a long term care facility. Which of the following are appropriate activities for the nurse to include in the care plan?

Correct Answer is A

Explanation

A client arrives with respiratory muscle weakness, difficulty swallowing and abdominal pain. Which of the following reported by the client's husband is relevant to the client's manifestations?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A client with a diagnosis of trigeminal neuralgia reports which of the following manifestations as significantly affecting her quality of life?

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which of the following responses by the nurse is most appropriate?

A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?

A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

When planning care for a client hospitalized with Guillain-Barre Syndrome, which of the following will the nurse report to the physician?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)