Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Check the blood pressure

Obtain a bladder scan

Notify the doctor

Elevate the head of the bed to 45 degrees

Answer and Explanation

The Correct Answer is D,A,B,C

Choice D reason: Elevating the head of the bed to 45 degrees is the first intervention the nurse should perform. This position helps lower the patient's blood pressure by promoting venous pooling in the lower extremities and reducing the return of blood to the heart. It also aids in better breathing and overall comfort.

Choice A reason: Checking the blood pressure is crucial in this situation to confirm if the patient is experiencing autonomic dysreflexia, which is characterized by a sudden and severe increase in blood pressure. This step helps in assessing the severity of the condition and guiding subsequent interventions.

Choice B reason: Obtaining a bladder scan is important because a full bladder is a common trigger of autonomic dysreflexia. By identifying and addressing the cause of the distension, the nurse can help alleviate the symptoms and prevent further complications.

Choice C reason: Notifying the doctor is a critical step, as autonomic dysreflexia is a medical emergency that requires prompt medical intervention. The healthcare provider can give additional orders and may administer medication to control the patient's blood pressure and relieve symptoms.

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Correct Answer is D

Explanation

Choice A reason: Cantaloupe and cottage cheese are not particularly high in iron. While cantaloupe provides vitamin C, which can enhance iron absorption, the overall iron content of this meal is low, making it less effective for treating iron-deficiency anemia.

Choice B reason: Cornmeal muffin and orange juice offer some nutrients, including vitamin C from orange juice, which helps with iron absorption. However, cornmeal muffins do not provide significant iron content, making this choice suboptimal for iron-deficiency anemia.

Choice C reason: Strawberry and banana fruit plate provides vitamins and minerals, including vitamin C from strawberries, but it lacks substantial iron content. This choice is not adequate for addressing iron-deficiency anemia.

Choice D reason: Omelet and whole wheat toast are excellent choices for increasing dietary iron intake. Eggs in the omelet provide heme iron, which is easily absorbed by the body, and whole wheat toast contains non-heme iron. Combined, they offer a balanced and effective meal for managing iron-deficiency anemia.

A. Clean the stoma two times a week. B. Use a bedside humidifier. C. Offer plenty of fluids to the patient. D. Keep the stoma uncovered when the patient showers.

Correct Answer is ["B"]

Explanation

Choice A reason: Cleaning the stoma two times a week is not sufficient. Stoma care typically requires daily cleaning to prevent infection and ensure the area remains free from mucus buildup and irritation.

Choice B reason: Using a bedside humidifier is important for patients with a tracheostomy. The humidified air helps to keep the stoma and airway moist, preventing drying and crusting of secretions, which can obstruct the airway.

Choice C reason: Offering plenty of fluids to the patient helps to keep the mucus thin and easier to clear, which is crucial for maintaining a clear airway in patients with a tracheostomy.

Choice D reason: Keeping the stoma uncovered when the patient showers is incorrect. The stoma should be covered with a waterproof shield or dressing to prevent water from entering the airway, which can cause respiratory distress or infection.

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Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia?

Correct Answer is D

Explanation

Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["B"]

Explanation

When caring for a patient with Alzheimer's disease, the nurse would assess the patient for which two common infection-related complications due to chronic dementia?

Which outcome would the nurse include in the care plan for a patient with multiple sclerosis (MS)? Select all that apply.

A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition?

The nurse works in a clinic located in a community where many of the residents are Hispanic. Which strategy, if implemented by the nurse, would decrease health care disparities and promote health equity for this community?

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.