Patient Data

Exhibits

For each of the findings listed, click to indicate which are consistent with the disease process of aortic aneurysm versus gastric cancer. Each column must have at least one response option selected.

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Following a motorcycle vehicle collision, an adult client can follow simple commands, but is oriented only to self. The client was not wearing a helmet at the time of the accident, and is exhibiting periorbital bruising with bloody drainage from both ears. Which assessment finding should the nurse identify as a life threatening condition?

A client returns to the unit following a cerebral angiogram via the femoral artery that was performed two hours ago. In assessing this client, which finding requires immediate intervention by the nurse?

Which of the following findings should the nurse prioritize?

A client is admitted to the intensive care unit (ICU) after surgical repair of an aortic abdominal aneurysm (AAA). Sodium nitroprusside is infusing for severe postoperative hypertension. Normal saline is also infusing at 50 mL/hr. When the client suddenly reports back pain, the nurse measures the client's vital signs to be a heart rate of 38 beats/minute and a blood pressure of 80/60 mm Hg. Which intervention should the nurse implement first?

A client with left ventricular failure complains of a hacking cough that worsens at night and further complains that shortness of breath sometimes occurs upon wakening. Which intervention should the nurse include in the bedtime preparation?

After six days on a mechanical ventilator, a client is extubated and placed on 40% oxygen via face mask. The client is awake and cooperative, but reports having a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if airway is restricted. Which intervention is most important for the nurse to implement?

Patient Data

A young adult male client is admitted to the emergency department (ED) following a motor vehicle collision and the nurse suspects that he has suffered a spinal cord injury (SCI). Which assessment finding, if present, will alert the nurse to suspect spinal shock?