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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.
B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.
C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.
D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.
Correct Answer is D
Explanation
A. A ketogenic diet does not focus on high sodium or high sugar, as high sugar intake would increase carbohydrate levels.
B. A ketogenic diet is high in fat rather than low in fat.
C. High carbohydrates are avoided in a ketogenic diet, as the goal is to limit carbohydrates to promote ketone production.
D. The ketogenic diet consists of high fat and low carbohydrates, which helps to manage seizure activity by altering the brain's energy source to ketones rather than glucose.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.