A nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Allow the client to control the timing and frequency of the therapy.

Limit visiting hours until the client begins to participate in therapy

Establish a plan of care with the client that sets attainable goals.

Inform the client that privileges are related to participation in therapy.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Allowing the client to control the timing and frequency of the therapy might seem beneficial, but it can lead to inconsistent participation and lack of progress. Structured therapy sessions are essential for rehabilitation, and while some flexibility is important, a completely client-controlled schedule may not provide the necessary consistency.

Choice B Reason:
Limiting visiting hours until the client begins to participate in therapy is not an effective approach. Social support from family and friends is crucial for the emotional well-being of the client and can actually motivate them to engage more in their rehabilitation efforts. Restricting visits could lead to increased feelings of isolation and resistance.

Choice C Reason:
Establishing a plan of care with the client that sets attainable goals is the most effective approach. Involving the client in their care plan fosters a sense of ownership and motivation. Setting realistic and achievable goals helps the client see progress, which can boost their confidence and willingness to participate in therapy.

Choice D Reason:
Informing the client that privileges are related to participation in therapy can be perceived as punitive and may not be effective in motivating the client. It is important to use positive reinforcement and encouragement rather than threats or restrictions to foster cooperation and engagement in the rehabilitation process.

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Correct Answer is C

Explanation

Choice A Reason:
The range of 0.5-1 L/min is significantly lower than the normal cardiac output for adults. Such low values could indicate severe heart failure or other critical conditions where the heart is unable to pump sufficient blood to meet the body's needs.

Choice B Reason:
A cardiac output of 10-12 L/min is higher than the normal range for adults at rest. This level of cardiac output might be seen during intense physical activity or in conditions like hyperthyroidism, where the heart pumps more blood to meet increased metabolic demands.

Choice C Reason:
The normal range for cardiac output in adults is typically between 4-6 L/min. This range represents the volume of blood the heart pumps per minute at rest, ensuring adequate perfusion of tissues and organs. Cardiac output can vary based on factors such as age, body size, and physical activity.

Choice D Reason:
A cardiac output of 15-20 L/min is extremely high and would generally be seen only during extreme physical exertion or in pathological conditions. Such high values are not typical for resting adults and indicate a state of increased cardiac demand.

A. Suction the nose. B. Notify the physician. C. Test the drainage for glucose. D. Ask the client to blow their nose.

Correct Answer is C

Explanation

Choice A Reason:
Suctioning the nose is not the first action to take. Suctioning can increase intracranial pressure and potentially cause further injury. It is important to first determine the nature of the drainage before taking any invasive actions.

Choice B Reason:
Notifying the physician is important, but it should be done after confirming the nature of the drainage. Testing the fluid for glucose can help determine if it is cerebrospinal fluid (CSF), which would indicate a serious complication requiring immediate medical attention.

Choice C Reason:
Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive test would confirm that the clear fluid is CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures and requires prompt intervention to prevent infection and other complications.

Choice D Reason:
Asking the client to blow their nose is contraindicated. Blowing the nose can increase intracranial pressure and exacerbate a CSF leak. It is important to avoid any actions that could worsen the condition until the nature of the drainage is confirmed.

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A nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What measurement is the normal range for cardiac output in adults?

Correct Answer is C

Explanation

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Which of the following is a key teaching point when educating a client about disseminated intravascular coagulation (DIC)?

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head. When planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention:

What is the purpose of a hemodynamic monitoring system?

An infusion at 3 mcg/kg/min. The drug is available as 600 mg in 1000 mL of fluid. The client weighs 150 pounds. Calculate. Do not round, if applicable.

The nurse is caring for a client who was admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has respirations of 22/min, and a bleeding laceration to the forehead. Which of the following is the priority nursing action at this time?

Administer heparin 1000 units per hour IV. The pharmacy supplies the heparin infusion as 25,000 units in 500 mL D5W. What will the IV pump be set to? Please include the unit of measures.

Which of the following are risk factors for disseminated intravascular coagulation (DIC)? (Select All that Apply.)

Which of the following diagnostic tests is commonly used to assess heart failure?