A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

To determine understanding of the procedure

To establish the need for psychological support

To identify possible surgical risks

To recognize resources needed postoperatively

Answer and Explanation

The Correct Answer is C

Choice A reason:
Determining the client's understanding of the procedure is important as it ensures informed consent and can help alleviate anxiety. However, while this is a necessary part of preoperative care, it may not be the immediate priority¹.

Choice B reason:
Establishing the need for psychological support is a valuable aspect of holistic care. It addresses the client's emotional well-being and can improve overall satisfaction with the surgical experience. Nonetheless, it is not the primary focus of the preoperative assessment².

Choice C reason:
Identifying possible surgical risks is the priority in a preoperative assessment. This includes evaluating the client's medical history, current health status, and any factors that could increase the risk of complications during or after surgery. A thorough risk assessment is crucial for planning safe surgical care and for making decisions about proceeding with the surgery¹³.

Choice D reason:
Recognizing resources needed postoperatively is part of discharge planning and is essential for ensuring continuity of care. While it is an important consideration, it is not the immediate priority during the preoperative assessment².

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:
Polyuria, or excessive urination, is not typically a direct complication of a cervical spinal cord injury. Polyuria can be related to other conditions such as diabetes or the use of diuretics.

Choice B reason:
A weakened gag reflex can be a complication of a cervical spinal cord injury, especially if the injury affects the nerves that supply the muscles involved in swallowing. This can increase the risk of aspiration and requires careful monitoring.

Choice C reason:
Hypotension, or low blood pressure, is a common complication following a spinal cord injury due to the disruption of the autonomic pathways that control blood pressure. This condition, known as neurogenic shock, can occur in the acute phase following the injury.

Choice D reason:
Hyperthermia, or elevated body temperature, is not a common direct complication of a cervical spinal cord injury. However, the injury can disrupt temperature regulation, leading to difficulty in either staying warm or cooling down, depending on the environment and level of injury.

Choice E reason:
An absence of bowel sounds can indicate a complication of a cervical spinal cord injury, as the injury may disrupt the normal functioning of the bowel. This can lead to ileus or bowel obstruction, which requires prompt medical attention.

A. Hypotension B. Poor skin turgor C. Ataxia D. Dilute urine

Correct Answer is C

Explanation

Choice A reason: Hypotension
Hypotension, or low blood pressure, can be a consequence of dehydration, which is a common complication of DI due to the excessive loss of water. However, hypotension is not a direct neurological effect of DI. It is more of a circulatory system response to the changes in fluid volume within the body.

Choice B reason: Poor skin turgor
Poor skin turgor is an indicator of dehydration, which can occur in DI due to the large volume of urine excreted. Skin turgor refers to the skin's ability to change shape and return to normal (elasticity), and it becomes less elastic when the body is dehydrated. While this is an important sign to monitor, it is not a neurological effect.

Choice C reason: Ataxia
Ataxia, which is a lack of muscle coordination affecting speech, eye movements, the ability to swallow, walking, picking up objects, and other voluntary movements, can be a neurological effect of DI if severe dehydration and electrolyte imbalance affect the brain. Symptoms such as confusion and muscle cramps can also be associated with ataxia, making it a relevant neurological effect to monitor in a client with DI.

Choice D reason: Dilute urine
Dilute urine is a primary symptom of DI, not a neurological effect. It is the result of the kidneys' inability to concentrate urine due to a deficiency in the anti-diuretic hormone (ADH) or the kidneys' response to ADH. Monitoring urine concentration is crucial in managing DI, but it does not represent a neurological effect.

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A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurological effects?

Correct Answer is C

Explanation

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