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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Dementia is not characterized by a sudden onset of confusion. It is a gradual and progressive condition.
Choice B Rationale: Dementia can be triggered or worsened by factors like infections, but it is not primarily characterized by a high fever or dehydration.
Choice C Rationale: An altered level of consciousness is not typically associated with dementia but may occur in acute delirium.
Choice D Rationale: The nurse should explain to the family that dementia is a chronic condition that affects the brain and causes cognitive impairment, memory loss, andbehavioral changes. The nurse should also inform the family that dementia is not caused by a single factor, but by a combination of genetic, environmental, and lifestyle factors. The nurse should emphasize that dementia is not a normal part of aging, and that it has different stages and types.
Correct Answer is C
Explanation
Choice A Rationale: Oral care is important for overall hygiene but may not take precedence over other critical aspects of care for a client with a spinal cord injury.
Choice B Rationale: Offering the client to discuss their feelings is important for emotional support but may not be the highest priority.
Choice C Rationale: Diet modifications are a high priority because they are essential for addressing the client's nutritional needs and preventing complications related to the spinal cord injury, such as pressure ulcers and infections.
Choice D Rationale: The application of compression stockings may have a role in the care plan but is not typically the highest priority for a client with a spinal cord injury.
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