The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?

Establish IV access and bolus 250 mL normal saline

Assess for bladder distension and perform digital disimpaction

Reschedule the therapy session for later in the day

Lower the head of the bed and obtain vital signs

Answer and Explanation

The Correct Answer is D

A. Establishing IV access may be necessary if hypotension persists but is not the initial priority.

B. Bladder distension assessment is essential for managing autonomic dysreflexia in SCI patients; however, symptoms here suggest orthostatic hypotension rather than autonomic dysreflexia.

C. Rescheduling therapy may be considered if dizziness persists, but it does not address the immediate concern.

D. Lowering the head of the bed and obtaining vital signs can help stabilize blood pressure and monitor for orthostatic hypotension, which is common in patients with SCI due to autonomic dysfunction. This intervention helps to prevent syncope.

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Free Nursing Study Resources

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

Explanation

Macular degeneration: This condition leads to the loss of central vision due to damage to the macula, which is responsible for sharp, straight-ahead vision.

Presbyopia: A common age-related condition resulting in a gradual loss of near visual acuity as the lens becomes less flexible, making it harder to focus on close objects.

Glaucoma: Typically causes loss of peripheral vision due to increased intraocular pressure damaging the optic nerve, eventually leading to tunnel vision if untreated.

Cataracts: Causes blurry vision as the lens becomes clouded, leading to general visual disturbance that progresses over time.

A. Surgery to remove the eye B. Referral for drug rehabilitation program C. Admission for IV and intravitreal antibiotics D. Follow up with eye specialist outpatient

Correct Answer is C

Explanation

A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.

B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.

C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.

D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.

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The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for several patients with eye disorders. Which assessment finding correlates with each diagnosis? Note: each column must have one response option selected. Note: Each category must have at least 1 response option selected.

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

Explanation

A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

Correct Answer is C

Explanation

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