Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
A. Raise the head of the bed.
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
B. Check the client for a fecal impaction.
Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
C. Check the client's bladder for distention.
Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
D. Ensure the room temperature is warm.
Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom MS Nurse Proctored Exam. Take the full exam now
Full Explanation
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
b. Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
c. Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
d. Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
Similar Questions
A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
A. Apply a compression bandage to the client's ankle.
B. Apply heat to the client's ankle.
C. Encourage range of motion of the client's foot.
D. Elevate the client's foot.
E. Check the client's toes for color, temperature, and sensation.
Full Explanation
These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.
Applying heat to the client's ankle is not recommended as it can increase swelling and inflammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the affected area.
A nurse is reinforcing teaching with a client who has multiple sclerosis and is learning how to use the four- point alternate gait with crutches. Identify the order of the steps the nurse should give to the client. (Move the steps of the four-point alternate gait into the box on the right placing them in the selected order of performance. Use all the steps.)
A. Move the right crutch about 10 to 15 cm (4 to 6 in).
B. Move the left foot forward.
C. Move the left crutch forward.
D. Move the right foot forward.
Full Explanation
The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait patern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.
A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)
A. Absence of pulse
B. Altered sensation of the toes
C. Cool skin
D. Pain relieved by narcotics
E. Capillary refill 1 second
Full Explanation
The nurse should identify absence of pulse, altered sensation of the toes, and cool skin as possible manifestations of compartment syndrome. Compartment syndrome is a serious condition that can occur following surgery or injury. It is characterized by increased pressure within a muscle compartment that can lead to decreased blood flow and nerve damage.
Pain relieved by narcotics and capillary refill of 1 second are not manifestations of compartment syndrome. Pain relieved by narcotics is a normal response to pain medication. Capillary refill of 1 second is within the normal range and does not indicate compartment syndrome.