A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action would the nurse take first?
Give the prescribed antiemetic.
Check for a fecal impaction.
Assess the blood pressure (BP).
Notify the health care provider.
The Correct Answer is C
Choice A reason: Giving an antiemetic treats nausea but doesn’t address the headache and nausea’s cause, likely autonomic dysreflexia in T3 injury. Assessing blood pressure identifies this emergency, making this secondary and incorrect compared to the nurse’s priority of evaluating the patient’s urgent symptoms.
Choice B reason: Checking for fecal impaction is relevant for autonomic dysreflexia but secondary to blood pressure assessment, which confirms the emergency. Immediate BP evaluation is critical, making this delayed and incorrect compared to the nurse’s first action for the patient’s symptoms.
Choice C reason: Assessing blood pressure first is critical, as headache and nausea in a T3 spinal cord injury patient suggest autonomic dysreflexia, a hypertensive emergency. This aligns with neurological nursing priorities, making it the correct initial action to address the patient’s urgent symptoms.
Choice D reason: Notifying the provider is important but follows assessing blood pressure to confirm autonomic dysreflexia. Immediate BP evaluation guides care, making this premature and incorrect compared to the nurse’s first action to evaluate the T3 injury patient’s headache and nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Showering and walking the next day are appropriate post-thyroidectomy activities, promoting mobility without strain. Expecting yellow drainage indicates a misunderstanding, as it suggests infection, making this correct and incorrect for needing further teaching, as it aligns with recovery expectations.
Choice B reason: Yellow drainage from the incision suggests infection, not a normal post-thyroidectomy expectation, indicating a need for further teaching. Normal drainage, if any, is minimal and serosanguinous, making this the correct choice, as it reflects a misconception requiring clarification in the patient’s recovery education.
Choice C reason: Avoiding heavy lifting is accurate, as it prevents strain on the surgical site post-thyroidectomy. Yellow drainage is an incorrect expectation, making this correct and incorrect for needing teaching, as it aligns with proper recovery restrictions to ensure healing and safety.
Choice D reason: Avoiding excessive neck extension is appropriate to protect the incision and promote healing post-thyroidectomy. Yellow drainage is a misconception, making this correct and incorrect for needing teaching, as it reflects proper understanding of activity limitations during the recovery period.
Correct Answer is B
Explanation
Choice A reason: CT scans can detect gallstones but are less specific and involve radiation, making them secondary to ultrasound. Ultrasound is the preferred test for its accuracy and safety, making this less optimal and incorrect compared to the primary diagnostic tool for confirming gallstones.
Choice B reason: Ultrasound is the most helpful test for confirming gallstones, offering high sensitivity and specificity without radiation. It visualizes stones clearly in the gallbladder, aligning with diagnostic guidelines, making it the correct choice for the nurse to identify as the primary radiographic test for gallstones.
Choice C reason: MRA focuses on vascular structures, not gallstones, and is irrelevant for gallbladder assessment. Ultrasound is the standard for gallstone confirmation, making this inappropriate and incorrect compared to the non-invasive, effective imaging method used in diagnosing gallbladder conditions.
Choice D reason: Abdominal x-rays detect only calcified gallstones, missing non-calcified ones, which are common. Ultrasound is more comprehensive, making this less reliable and incorrect compared to the preferred diagnostic test for accurately confirming gallstones in a clinical setting.
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