The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?

Establish IV access and bolus 250 mL normal saline

Assess for bladder distension and perform digital disimpaction

Reschedule the therapy session for later in the day

Lower the head of the bed and obtain vital signs

Answer and Explanation

The Correct Answer is D

A. Establishing IV access may be necessary if hypotension persists but is not the initial priority.

B. Bladder distension assessment is essential for managing autonomic dysreflexia in SCI patients; however, symptoms here suggest orthostatic hypotension rather than autonomic dysreflexia.

C. Rescheduling therapy may be considered if dizziness persists, but it does not address the immediate concern.

D. Lowering the head of the bed and obtaining vital signs can help stabilize blood pressure and monitor for orthostatic hypotension, which is common in patients with SCI due to autonomic dysfunction. This intervention helps to prevent syncope.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"D"},"C":{"answers":"B"},"D":{"answers":"C"}}

Explanation

Macular degeneration: This condition leads to the loss of central vision due to damage to the macula, which is responsible for sharp, straight-ahead vision.

Presbyopia: A common age-related condition resulting in a gradual loss of near visual acuity as the lens becomes less flexible, making it harder to focus on close objects.

Glaucoma: Typically causes loss of peripheral vision due to increased intraocular pressure damaging the optic nerve, eventually leading to tunnel vision if untreated.

Cataracts: Causes blurry vision as the lens becomes clouded, leading to general visual disturbance that progresses over time.

A. "Using three drugs at the same time enhances suppression of viral replication." B. "If the virus becomes resistant to this combination, I will be switched to another combination of medications." C. "Because the combination of medications kills the virus, I can stop taking the medications." D. "My CD4 count should increase with this medication regimen."

Correct Answer is C

Explanation

A. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.

B. This is accurate; if resistance develops, alternative medications or combinations can be considered.

C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.

D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.

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The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for several patients with eye disorders. Which assessment finding correlates with each diagnosis? Note: each column must have one response option selected. Note: Each category must have at least 1 response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"D"},"C":{"answers":"B"},"D":{"answers":"C"}}

Explanation

Which statement made by a patient who is diagnosed with human immunodeficiency virus (HIV) and is prescribed three antiretroviral medications, indicates the need for further teaching about the medication combination?

Correct Answer is C

Explanation

The nurse teaching a patient who is diagnosed with human immunodeficiency virus (HIV), would include which information regarding an activity that has the highest potential to spread the disease to relatives or friends in a household?

The nurse anticipates which of the following as a prescription for patient diagnosed with Meniere's Disease?

The patient diagnosed with acquired immunodeficiency syndrome (AIDS) states that they have developed purple, brown spots on their body. Which opportunistic infection does the nurse suspect?

The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?

The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?