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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A Rationale: Using antipsychotics around the clock is not an appropriate approach for managing Alzheimer's disease and may have adverse effects.
Choice B Rationale: "She will not be left home alone" indicates effective teaching because it emphasizes the importance of supervision and safety for a client with Alzheimer's who may be at risk of wandering or accidents.
Choice C Rationale: Applying a restraint to only one wrist is not an appropriate or effective strategy for managing Alzheimer's-related behaviors and may have ethical concerns.
Choice D Rationale: Placing rugs in the bathroom may create tripping hazards for a client with Alzheimer's. Effective teaching should focus on removing hazards rather than adding them.
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