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 A

Explanation

Choice A Rationale: Keeping window blinds open during the day is a non pharmacological approach to help regulate the patient's circadian rhythm and may reduce the severity of sundowning, a common phenomenon in dementia.

Choice B Rationale: Having the patient take a mid-morning nap may disrupt the patient's sleep-wake cycle and worsen sundowning.

Choice C Rationale: Providing hourly orientation to time and place may be overwhelming for the patient and not necessarily effective in addressing sundowning.

Choice D Rationale: Moving the patient to a quiet room in the afternoon may not address the underlying issue of sundowning and may not be practical in a long-term care setting.

A. A Patient who developed a new cough after eating breakfast B. B Patient who is refusing to take the prescribed medications. C. C Patient who has not had a bowel movement for 5 days. D. D Patient who has a stage Il pressure ulcer on the coccyx

Correct Answer is A

Explanation

Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.

Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.

Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.

Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.

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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

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

Correct Answer is A

Explanation

After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?

Correct Answer is A

Explanation

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 client with Alzheimer's is having increased behavioral issues that have become a safety concern for the client and others. Which of the following medications will the nurse discuss with the physician for inclusion in the client's care plan?

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 new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?

A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?

During a client interview, the nurse notices that the client often fills in information with made-up stories. Which stage of Alzheimer's disease will the nurse see this behavior?

The nurse caring for the client with Alzheimer's documents that the client is in the early stage of Alzheimer's. Which findings are consistent with mild Alzheimer's disease?