A client arrives with respiratory muscle weakness, difficulty swallowing and abdominal pain. Which of the following reported by the client's husband is relevant to the client's manifestations?

The client received an influenza vaccine 4 weeks ago

The client is an avid golfer

The client cans jams and preserves

The client has a history of diabetes

Answer and Explanation

The Correct Answer is A

Choice A Rationale: The client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.

Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.

Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.

Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.

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Correct Answer is A

Explanation

Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.

Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.

Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.

Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.

A. Sedatives B. Antipsychotics C. Cholinesterase inhibitors D. Serotonin Reuptake inhibitors

Correct Answer is B

Explanation

Choice A Rationale: Sedatives may not be the first choice for managing behavioral issues in clients with Alzheimer's disease, as they can increase confusion and fall risk.

Choice B Rationale: Antipsychotics may be considered in cases where behavioral issues pose a safety concern. They can help manage agitation, aggression, and other challenging behaviors.

Choice C Rationale: Cholinesterase inhibitors are used to treat cognitive symptoms of Alzheimer's disease but may not directly address behavioral issues.

Choice D Rationale: Serotonin reuptake inhibitors are typically used to manage mood disorders and may not be the first-line choice for behavioral issues in Alzheimer's disease.

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A client arrives with respiratory muscle weakness, difficulty swallowing and abdominal pain. Which of the following reported by the client's husband is relevant to the client's manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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