Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Administer a prescribed PRN dose of hydralazine.

Assess the client's blood pressures every 15 minutes.

Teach the client to recognize the symptoms of dysreflexia.

Relieve any kinks or obstruction in the client's Foley tubing.

Answer and Explanation

The Correct Answer is D

A)   This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B)   Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C)   Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D)   The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

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Correct Answer is C

Explanation

A) Incorrect - Developing and implementing new screening protocols does not directly indicate the effectiveness of a primary prevention program. It might indicate improved detection, but not necessarily prevention.
B) Incorrect - This outcome relates to secondary prevention (rehabilitation after disease complications) rather than primary prevention.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is an outcome of early detection (secondary prevention), not primary prevention.

A. Pain assessments B. Antibiotics C. Occupational therapy D. Wound care E. Physical therapy

Correct Answer is A

Explanation

Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being.

While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence.

Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively.

These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.

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Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

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