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A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>

The client is at risk for developing

due to.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.


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Related Questions

Correct Answer is A

Explanation

A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.

B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.

C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.

D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

Cardiovascular abnormalities are a serious risk in clients with bulimia nervosa due to electrolyte imbalances, especially hypokalemia, which can lead to arrhythmias, weakened heart muscles, and potential heart failure. Hyponatremia (low sodium levels) can occur due to excessive vomiting, which leads to the loss of fluids and electrolytes, including sodium. Incorrect responses: Group 1: Hypoglycemia: Bulimia nervosa primarily causes electrolyte imbalances and acid-base disturbances due to vomiting, not significant alterations in blood sugar levels. Metabolic Acidosis: Vomiting leads to the loss of gastric acid, causing metabolic alkalosis. Hypotension: Hypotension could occur if the client experiences significant dehydration from vomiting. Hypotension would be a consequence of severe dehydration rather than a primary risk at this stage. Hyperglycemia: Hyperglycemia is not typically associated with bulimia nervosa or vomiting. It would be more relevant in conditions like diabetes. Group 2: Hyperkalemia: Hyperkalemia (high potassium) is unlikely in bulimia nervosa, where frequent vomiting usually leads to hypokalemia due to the loss of potassium in gastric secretions. Metabolic Acidosis: As mentioned before, vomiting leads to metabolic alkalosis, not acidosis, because of the loss of hydrochloric acid. Hypochloremia: Hypochloremia (low chloride levels) can occur with vomiting due to the loss of stomach acid, which contains chloride. While it is a possible outcome, metabolic alkalosis better captures the overall acid-base disturbance in the client.

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