The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital?

Monitor the Glasgow Coma Scale.

Complete the Braden Scale.

Initiate a Brudzinski flow sheet.

Assess for Babinski's sign.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.

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Correct Answer is B

Explanation

Choice A reason:

Increased temperature is not a typical finding associated with fluid volume overload. Fluid volume overload affects the circulatory and respiratory systems primarily, and while fever can indicate infection or inflammation, it is not a direct consequence of fluid volume excess.

Choice B reason:

Increased blood pressure is a common finding in fluid volume overload due to the increased volume of blood in the circulatory system. This excess volume can lead to hypertension as the heart works harder to pump the additional fluid, making this a key indicator of fluid volume overload.

Choice C reason:

Bradycardia, or a slow heart rate, is not typically associated with fluid volume overload. In fact, fluid overload often leads to tachycardia as the heart tries to compensate for the increased volume. Bradycardia could indicate other cardiac conditions but is not a sign of fluid volume excess.

Choice D reason:

Increased hematocrit is not expected in fluid volume overload. Hematocrit measures the proportion of red blood cells in the blood, and with fluid overload, this proportion is usually diluted, leading to a lower hematocrit level rather than an increased one.

A. This drug may be used in maintenance treatment for heart failure. B. This medication may take weeks to see effects. C. Limit use of the drug to 3 days to prevent rebound nasal congestion. D. Take this drug at bedtime because it may cause drowsiness.

Correct Answer is C

Explanation

Choice A reason:

Oxymetazoline is not used for maintenance treatment of heart failure. It is a topical decongestant used to relieve nasal congestion and is not indicated for cardiac conditions.

Choice B reason:

Oxymetazoline provides rapid relief of nasal congestion and does not take weeks to show effects. Its action is almost immediate, making it effective for short-term use.

Choice C reason:

Limiting the use of oxymetazoline to 3 days is crucial to prevent rebound nasal congestion, a condition where the nasal passages become more congested once the medication is stopped. Overuse can lead to dependency and worsening congestion.

Choice D reason:

Oxymetazoline does not typically cause drowsiness, so taking it at bedtime is not necessary. This statement does not apply to the pharmacological effects of this medication.

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The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with fluid volume overload. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

The nurse is caring for a client currently taking oxymetazoline. Which of the following statements should the nurse include regarding oxymetazoline?

Correct Answer is C

Explanation

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