Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
A. Monitor for elevated blood pressure.
Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreflexia.
B. Provide analgesia for headaches.
Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreflexia.
C. Prevent bladder distention.
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.
D. Elevate the client's head.
Elevating the client's head is important but not an intervention to prevent autonomic dysreflexia.
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Full Explanation
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.
a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreflexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreflexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreflexia.
Similar Questions
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?
A. Obtain a throat culture specimen.
Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Perform a complete blood count.
Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.
C. Check the client's temperature.
Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.
D. Administer an oral analgesic.
Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.
Full Explanation
A. Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.
C. Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.
D. Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.
A nurse is caring for a client who has osteoporosis and is taking calcium carbonate. The nurse should monitor the client for which of the following adverse effects?
A. Urinary retention
Urinary retention is not a common adverse effect of calcium carbonate.
B. Tinnitus
Tinnitus is not a common adverse effect of calcium carbonate.
C. Flank pain
The nurse should monitor the client for flank pain as an adverse effect of taking calcium carbonate. Calcium carbonate is a calcium supplement used to prevent or treat a calcium deficiency¹. One of the side effects of calcium carbonate is the formation of kidney stones, which can cause flank pain.
D. Bradycardia
Bradycardia is not a common adverse effect of calcium carbonate.
Full Explanation
The nurse should monitor the client for flank pain as an adverse effect of taking calcium carbonate. Calcium carbonate is a calcium supplement used to prevent or treat a calcium deficiency¹. One of the side effects of calcium carbonate is the formation of kidney stones, which can cause flank pain².
a. Urinary retention is not a common adverse effect of calcium carbonate.
b. Tinnitus is not a common adverse effect of calcium carbonate.
d. Bradycardia is not a common adverse effect of calcium carbonate.
A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?
A. Pivot
The knee is not a pivot joint.
B. Hinge
The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for flexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia.
C. Ball and socket
The knee is not a ball and socket joint.
D. Gliding
The knee is not a gliding joint.
Full Explanation
The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for flexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia.
a. The knee is not a pivot joint.
c. The knee is not a ball and socket joint.
d. The knee is not a gliding joint.