Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Check the blood pressure

Obtain a bladder scan

Notify the doctor

Elevate the head of the bed to 45 degrees

Answer and Explanation

The Correct Answer is D,A,B,C

Choice D reason: Elevating the head of the bed to 45 degrees is the first intervention the nurse should perform. This position helps lower the patient's blood pressure by promoting venous pooling in the lower extremities and reducing the return of blood to the heart. It also aids in better breathing and overall comfort.

Choice A reason: Checking the blood pressure is crucial in this situation to confirm if the patient is experiencing autonomic dysreflexia, which is characterized by a sudden and severe increase in blood pressure. This step helps in assessing the severity of the condition and guiding subsequent interventions.

Choice B reason: Obtaining a bladder scan is important because a full bladder is a common trigger of autonomic dysreflexia. By identifying and addressing the cause of the distension, the nurse can help alleviate the symptoms and prevent further complications.

Choice C reason: Notifying the doctor is a critical step, as autonomic dysreflexia is a medical emergency that requires prompt medical intervention. The healthcare provider can give additional orders and may administer medication to control the patient's blood pressure and relieve symptoms.

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Correct Answer is D

Explanation

Choice A reason: Anticipating obtaining a throat swab for rapid streptococcus testing is not immediately related to the use of a budesonide inhaler. This test is typically done when there is a suspicion of a streptococcal infection, not specifically for managing asthma medication side effects.

Choice B reason: Offering reassurance that the symptoms are common with budesonide use may not fully address the patient’s concern or prevent potential complications. It is more effective to provide actionable advice that can help manage the symptoms.

Choice C reason: Suggesting that the patient stop using the spray until the symptoms are resolved could potentially worsen asthma control. Budesonide is an important medication for managing asthma, and discontinuing it without alternative treatment may lead to exacerbation of symptoms.

Choice D reason: Teaching the patient to gargle with water after using the budesonide inhaler is the most appropriate action. This practice helps to reduce the risk of developing oral thrush, a common side effect of inhaled corticosteroids like budesonide. Gargling with water removes any residual medication in the mouth, thereby minimizing the risk of infection.

A. Oxygen mask B. Nasogastric tube C. Urinary catheter D. Suction set-up E. Tongue blade F. Side rail pads

Correct Answer is ["A","D","F"]

Explanation

Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.

Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.

Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.

Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.

Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.

Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.

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Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a patient with asthma who is on a budesonide hand-held inhaler reports difficulty, what should the nurse do?

Correct Answer is D

Explanation

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply)

Correct Answer is ["A","D","F"]

Explanation

The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

The nurse admits a patient with a low BP who reports severe diarrhea for several days from a Clostridium difficile infection. Which IV fluid would the nurse associate with the need to rapidly replace the patient's fluid volume?

Physical signs of unrelieved pain include which of the following? Select all that apply.

A nurse is caring for a patient diagnosed with thrombocytopenia. Which of the following interventions should the nurse prioritize to ensure the safety of the patient?

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.

Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.