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","D","E"]

Explanation

A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.

B. Soft wrist restraints are not required in this scenario unless otherwise indicated.

C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.

D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.

E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.

A. Conjunctivitis B. Retinal Detachment C. Corneal abrasion D. Chalzion

Correct Answer is C

Explanation

A. Conjunctivitis (pink eye) is not a typical complication of Bell's Palsy.

B. Retinal detachment is unrelated to the incomplete eye closure seen in Bell’s Palsy.

C. Bell's Palsy often results in incomplete eye closure, which can lead to drying and irritation of the cornea, increasing the risk for corneal abrasions. An eye patch protects the cornea by helping the eye stay moist and protected from injury.

D. A chalazion is a small eyelid bump caused by blocked oil glands, not associated with Bell’s Palsy.

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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 a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

Correct Answer is C

Explanation

The nurse is the first person on the scene of a motor vehicle crash. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?

The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

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 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 patient who is diagnosed with a seizure disorder is prescribed a ketogenic diet. The nurse knows that the patient understands the teaching when they state, "My diet will include:

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

The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

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