The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).

Severe fluid and electrolyte imbalance

Upper abdominal distention

Metabolic acidosis

Projectile vomiting with a fecal odor

Diarrhea or ribbon-like stools

Answer and Explanation

Correct Answer : A,B,D

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Correct Answer is A

Explanation

Choice A reason: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure. This is because the full bladder sends signals to the spinal cord, which then attempts to send signals to the brain. However, due to the injury, these signals cannot pass through, resulting in a reflex that increases blood pressure.

Choice B reason: While a severe headache is a symptom of autonomic dysreflexia, it is not a cause. The headache results from the body's response to a triggering stimulus, such as a distended bladder, which leads to the high blood pressure characteristic of autonomic dysreflexia.

Choice C reason: Nasal congestion is not typically a cause of autonomic dysreflexia. The condition is usually triggered by a noxious stimulus below the level of the spinal cord injury, such as a full bladder or bowel, skin irritation, or other types of physical discomfort.

Choice D reason: Elevated blood pressure is a symptom, not a cause, of autonomic dysreflexia. The condition itself causes a sudden spike in blood pressure due to an uncontrolled reflex sympathetic discharge in response to a triggering stimulus below the level of the injury.

Correct Answer is ["0.2"]

Explanation

- Step 1: Identify the required dose in milligrams (mg). The nurse is scheduled to administer 2 mg of morphine sulfate.

- Step 2: Identify the concentration of the available solution. The available solution contains 10 mg of morphine sulfate per 1 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 10 mg is to 1 mL as 2 mg is to X mL.

- In other words, 10 mg : 1 mL = 2 mg : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 10 mg × X mL = 2 mg × 1 mL.

- Simplifying this gives us: 10X = 2.

- Dividing both sides by 10 gives us: X = 2 ÷ 10.

- Calculating the division gives us: X = 0.2.

So, the nurse should administer 0.2 mL of the morphine sulfate solution per dose.

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The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?

Correct Answer is A

Explanation

A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.2"]

Explanation

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