The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:
Temp: 99.0°F
HR: 46 beats/min
BP: 78/52 mmHg
RR: 20 breaths/min
SaO2: 94% on 2L NC
Which of the following interventions should the nurse anticipate?

Suction the patient immediately.

NS at 25 cc/hr.

Raise the head of the bed.

Dopamine IV drip.

HR: 46 beats/min

Answer and Explanation

The Correct Answer is D

Choice A reason: Suctioning the patient immediately is not the appropriate intervention in this context. Suctioning can be necessary if the patient has secretions obstructing the airway, but it does not address the issues of bradycardia (low heart rate) and hypotension (low blood pressure) which are critical in a spinal cord injury.

Choice B reason: Administering normal saline (NS) at 25 cc/hr is not sufficient to address the patient's hypotension. In a patient with a spinal cord injury at the T5 level, hypotension is likely due to neurogenic shock, and more aggressive fluid resuscitation or pharmacological support is needed.

Choice C reason: Raising the head of the bed is not appropriate for managing the patient's condition. In fact, keeping the head elevated can worsen hypotension by reducing venous return to the heart. The focus should be on stabilizing blood pressure and heart rate.

Choice D reason: The correct intervention is starting a dopamine IV drip. Dopamine is a vasopressor that helps increase blood pressure and heart rate, which is crucial in managing neurogenic shock. By administering dopamine, the nurse can help stabilize the patient's cardiovascular status and improve perfusion to vital organs.

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Correct Answer is B

Explanation

Choice A reason: Suctioning every 2 hours is not appropriate for a patient with increased intracranial pressure (ICP). Suctioning can increase ICP due to the stress and stimulation it causes. It should only be performed when absolutely necessary and with proper precautions to minimize ICP spikes.

Choice B reason: Providing rest periods between nursing procedures is the correct measure. This helps minimize stimulation and stress, which can increase ICP. Rest periods allow the patient to stabilize and reduce the risk of further increasing the pressure within the skull.

Choice C reason: Encouraging active range of motion exercises is not suitable for a patient with increased ICP. Physical activity can exacerbate the condition by increasing intracranial pressure. The focus should be on minimizing activity and stress to prevent further elevation of ICP.

Choice D reason: Assigning the patient to a semiprivate room near the nurse's station is not the best approach. Patients with increased ICP require a quiet and calm environment to help manage their condition. A semiprivate room near the nurse's station may expose the patient to more noise and activity, which could increase ICP.

A. The client needs a muscle relaxant. B. The client has a nutritional imbalance. C. The client is experiencing a reaction to morphine. D. The client may be developing hypocalcemia.

Correct Answer is D

Explanation

Choice A reason: Administering a muscle relaxant addresses the symptom of muscle twitching and jerking, but it does not identify or treat the underlying cause. For patients with acute pancreatitis, muscle twitching and jerking could be indicative of a more serious condition.

Choice B reason: While a nutritional imbalance could potentially lead to symptoms like muscle twitching and jerking, in the context of acute pancreatitis, the nurse should consider more specific causes related to the condition. Nutritional imbalances do not usually explain these symptoms in patients with pancreatitis as well as hypocalcemia does.

Choice C reason: A reaction to morphine could include various symptoms such as itching, nausea, or constipation, but muscle twitching and jerking are not common side effects. The nurse should consider other causes related to the patient's condition of acute pancreatitis.

Choice D reason: Hypocalcemia, or low calcium levels, is a common complication of acute pancreatitis. It can lead to symptoms such as muscle twitching and jerking, as calcium is crucial for proper muscle function and nerve signaling. This makes hypocalcemia the most relevant and accurate interpretation of the patient's symptoms in this context.

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The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:Temp: 99.0°FHR: 46 beats/minBP: 78/52 mmHgRR: 20 breaths/minSaO2: 94% on 2L NCWhich of the following interventions should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

Correct Answer is B

Explanation

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the relevance of these symptoms?

Correct Answer is D

Explanation

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?

A patient is admitted with acute kidney injury and the following assessment cues: K: 6.9 (3.5-5.0) Cr: 3.2 (0.6-1.2) Urine: 300 mL/24 hrs What priority actions should be anticipated by the nurse? Select all that apply.

The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.

The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:Temp: 99.0°FHR: 46 beats/minBP: 78/52 mmHgRR: 20 breaths/minSaO2: 94% on 2L NCWhich of the following interventions should the nurse anticipate?

Nursing interventions such as taking daily weights, I&O, and monitoring specific gravity relate to which kidney function?

What condition does the nurse suspect when a patient involved in a motor vehicle accident arrives at the emergency department with ecchymosis behind the ears and bleeding from the ears?

The nurse has completed an assessment on a client with heart failure and a decreased cardiac output with an ejection fraction of 30%. Which finding should receive the highest priority?

Which specific drug therapy will the nurse anticipate for management of the client who has septic shock?

The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:
Temp: 99.0°F
HR: 46 beats/min
BP: 78/52 mmHg
RR: 20 breaths/min
SaO2: 94% on 2L NC
Which of the following interventions should the nurse anticipate?