The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?

Signs of sympathetic stimulation

Hypertension

Cool, moist skin

Bradycardia

Answer and Explanation

The Correct Answer is D

A. Neurogenic shock is characterized by the loss of sympathetic tone, leading to parasympathetic predominance. Therefore, signs of sympathetic stimulation, such as tachycardia or sweating, are not present.
B. Neurogenic shock typically causes hypotension, not hypertension, due to vasodilation and decreased systemic vascular resistance.
C. Cool, moist skin is more commonly seen in hypovolemic or septic shock due to peripheral vasoconstriction. In neurogenic shock, vasodilation leads to warm, dry skin.
D. Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.

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Correct Answer is B

Explanation

A. While the time of the burn can provide information about the potential progression of injury, it is not the primary factor in determining the severity of the burn.
B. The depth of the burn is crucial for assessing the severity of the injury as it directly impacts the treatment required and the potential for complications. Depth determines whether the burn is superficial, partial-thickness, or full-thickness.
C. The cause of the burn is relevant for understanding the mechanism of injury but does not directly affect the assessment of burn severity.
D. The location of the burn is important for assessing potential complications and functional impairment but is secondary to the depth of the burn when determining overall severity.

A. Place the client on droplet precautions. B. Insert an indwelling urinary catheter. C. Place the client in a private room D. Check the client's rectal temperature once daily. E. Rinse the client's mouth with 0.9% sodium chloride every 4 hours

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.

A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.

The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.

Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.

Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.

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The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is B

Explanation

A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer. Exhibits For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

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A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?