A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.
Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>
The client is at risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.
Correct Answer is D
Explanation
A. This choice is incorrect because verapamil and TPN do not have a significant food and medication interaction. Verapamil is a calcium channel blocker that can lower blood pressure and heart rate, while TPN is a form of intravenous nutrition that provides calories, electrolytes, vitamins, and minerals. The nurse should monitor the client's vital signs and blood glucose levels, but there is no need to intervene to prevent an interaction.
B. This choice is incorrect because phenytoin and milkshakes do not have a significant food and medication interaction. Phenytoin is an anticonvulsant that can decrease the absorption of some vitamins, such as folic acid and vitamin D, but milkshakes are not a major source of these nutrients. The nurse should encourage the client to eat a balanced diet and take supplements as prescribed, but there is no need to intervene to prevent an interaction.
C. This choice is incorrect because potassium-rich foods and furosemide do not have a significant food and medication interaction. Furosemide is a loop diuretic that can cause hypokalemia, or low potassium levels, but potassium-rich foods can help prevent this complication. The nurse should monitor the client's electrolyte levels and fluid balance, but there is no need to intervene to prevent an interaction.
D. This choice is correct because MAOIs and cheeseburgers have a significant food and medication interaction. MAOIs are antidepressants that can cause hypertensive crisis, or dangerously high blood pressure, if the client consumes foods that contain tyramine, such as aged cheeses, cured meats, fermented foods, and beer. The nurse should intervene to prevent the client from eating a cheeseburger and educate the client about avoiding tyramine-containing foods while taking MAOIs.
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