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 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.

A. "I should discuss all over the counter drugs with my healthcare provider." B. "I cannot discontinue medication abruptly." C. "If I miss a dose, I can double up on the next dose." D. "I should take my medications exactly as ordered."

Correct Answer is C

Explanation

A. Discussing over-the-counter drugs with the healthcare provider is essential, as they can interact with antiepileptic medications.

B. Discontinuing antiepileptic medications abruptly can lead to rebound seizures and is unsafe, so this statement is correct.

C. Doubling up on doses can lead to toxicity and adverse effects; missed doses should not be made up by doubling the next dose. This response indicates the need for further teaching.

D. Taking medications exactly as prescribed is necessary to maintain therapeutic levels and manage seizure control effectively.

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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?

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Naxlex Comprehensive Predictor Exams

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 is caring for a patient diagnosed with epilepsy who is prescribed antiepileptic medications. The nurse would identify the need for further teaching when the patient states:

Correct Answer is C

Explanation

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