A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?

Check the client's phenytoin (Dilantin) level.

Get an order to decrease the rate of IV fluids.

Ask the woman to describe how she's feeling.

Offer the client clear liquids to prevent dehydration.

Answer and Explanation

The Correct Answer is C

A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.

B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.

C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.

D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.

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Correct Answer is B

Explanation

A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.

B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.

C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.

D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.

A. Catheterize for residual urine after voiding. B. Instruct the patient how to self-catheterize. C. Assist the patient to the toilet every 2 hours. D. Teach the patient to use the Credé method.

Correct Answer is B

Explanation

A. Catheterize for residual urine after voiding: While catheterization for residual urine may be necessary in some cases, it is not the most appropriate long-term solution for managing a neurogenic reflexic bladder. It does not promote patient independence or long-term bladder health.

B. Instruct the patient how to self-catheterize: Self-catheterization empowers the patient to manage their bladder function independently and reduces the risk of urinary tract infections
associated with indwelling catheters. It is the preferred method for managing neurogenic bladder in patients with spinal cord injury.

C. Assist the patient to the toilet every 2 hours: While assisting the patient to the toilet at regular intervals may help prevent urinary accidents, it does not address the underlying issue of neurogenic bladder or promote long-term bladder management.

D. Teach the patient to use the Credé method: The Credé method involves applying manual pressure to the bladder to promote voiding. While it may be used in some situations, it is not the preferred method for managing neurogenic bladder, especially in patients with spinal cord injury.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?