NUR 213: Test 4- ARDS, SCI, and Violence NCLEX questions

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1.Take the temperature. 2.Listen to breath sounds. 3.Observe for dyskinesias. 4.Assess extremity muscle strength.

2.Listen to breath sounds. Rationale: Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1.Altered breathing pattern 2.Increased likelihood of injury 3.Ineffective oxygen consumption 4.Increased susceptibility to aspiration

1.Altered breathing pattern Rationale: Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? 1.Assess the child's physical status. 2.Ask the child how the injury occurred. 3.Report the case as suspected child abuse. 4.Observe the interactions between the child and his friends.

1.Assess the child's physical status. Rationale: The initial intervention is to assess the child's physical status. The child should be initially assessed for injury to the right arm and for bruises, burns, scars, and any other signs of abuse. The nurse would next report the case as suspected child abuse to the appropriate authorities. Option 2 may or may not be appropriate, depending on the situation because the child may be fearful of telling the truth about how the injury occurred. Option 4, although appropriate for some situations, is not appropriate as the initial intervention.

The primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication should the nurse expect to be prescribed and administered by this route? 1.Baclofen 2.Chlorzoxazone 3.Dantrolene sodium 4.Cyclobenzaprine hydrochloride

1.Baclofen Rationale: Baclofen is the skeletal muscle relaxant that can be administered intrathecally, which means within the spinal column. Therefore, the remaining options are incorrect.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client? 1.Pallor 2.Low arterial PaO2 3.Elevated arterial PaO2 4.Decreased respiratory rate

2.Low arterial PaO2 Rationale: The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1.Bradycardia 2.Hyperthermia 3.Hypoglycemia 4.Increased cardiac output

1.Bradycardia Rationale: Neurogenic shock can occur after a spinal cord injury. Usually the body attempts to compensate massive vasodilation by becoming tachycardic to increase the amount of blood flow and oxygen delivered to the tissues; however, in neurogenic shock, the sympathetic nervous system is disrupted, so the parasympathetic system takes over, resulting in bradycardia. This insufficient pumping of the heart leads to a decrease in cardiac output. Hypoglycemia is not an indicator of neurogenic shock. Hypothermia develops because of the vasodilation and the inability to control body temperature through vasoconstriction.

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? 1.Information regarding shelters 2.Instructions regarding calling the police 3.Instructions regarding self-defense classes 4.Explaining the importance of leaving the violent situation

1.Information regarding shelters Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 4.Turning and repositioning the client at least every 2 hours Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see if which baseline study has been done? 1.Liver function studies 2.Renal function studies 3.Otoscopic examination 4.Blood glucose measurements

1.Liver function studies Rationale: Dantrolene is a skeletal muscle relaxant and can cause liver damage; therefore, the nurse should monitor the results of liver function studies. They should be done before therapy starts and periodically throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The incorrect options are not specifically related to the administration of this medication.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1.Monitor closely for harm to self or others. 2.Assist in completing an application for admission. 3.Supply the client with written information about her or his mental health problem. 4.Provide an opportunity for the family to discuss why they felt the admission was needed.

1.Monitor closely for harm to self or others. Rationale: Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the mental health problem, is likely premature initially. The family may have had no role to play in the client's admission.

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. 1.Raise the head of the bed 2.Check for bladder distention 3.Contact the primary health care provider (PHCP). 4.Loosen tight clothing on the client. 5.Administer an antihypertensive medication. 6.Document the occurrence, treatment, and response.

1.Raise the head of the bed 4.Loosen tight clothing on the client. 2.Check for bladder distention 3.Contact the primary health care provider (PHCP). 5.Administer an antihypertensive medication. 6.Document the occurrence, treatment, and response. Rationale: Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and to remove the noxious stimulus. The nurse would loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse also would check for a fecal impaction and would disimpact the client, if necessary. The PHCP is then contacted, especially if these actions do not relieve the signs and symptoms. Antihypertensive medication may be prescribed by the PHCP to minimize cerebral hypertension. Finally, the nurse documents the occurrence, treatment, and client response.

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which assessment finding should the nurse expect to note? 1.Continuous rapid regular breathing 2.Periods of apnea followed by bradypnea 3.Periods of apnea followed by deep rapid breathing 4.Periods of bradypnea followed by periods of tachypnea

3.Periods of apnea followed by deep rapid breathing Rationale: Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. The descriptions in the remaining options are incorrect.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. 1.Using a RotoRest bed 2.Ensuring that weights hang freely 3.Removing the weights to reposition the client 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use

1.Using a RotoRest bed 2.Ensuring that weights hang freely 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use Rationale: Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2. Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2. Leaving the client in an unchilled area of the room Rationale: The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response? 1."I agree. What do you want to bet he did it?" 2."Have you shared your concerns with the police?" 3."I don't think that you should blame yourself one little bit." 4."It feels terrible to lose a daughter. Your suspicions are only natural."

2."Have you shared your concerns with the police?" Rationale: The correct option addresses the subject of the client's statement. Avoid options that identify the process of agreeing with the client. The option of telling the client not to blame themselves is not directly related to the subject of the client's statement.

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? 1."I will use a straw for drinking." 2."I will drive only during the daytime." 3."I will be careful because the device alters balance." 4.I will wash the skin daily under the lamb's wool liner of the vest."

2."I will drive only during the daytime." Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all, because the device impairs the range of vision.

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1.A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2.A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3.A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4.A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

2.A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected Rationale: The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time.

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp

2.Difficulty walking Rationale: Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Fear of the parents and bald spots on the scalp most likely are associated with physical abuse.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? 1.Edema 2.Dyspnea 3.Frothy sputum 4.Diminished breath sounds

2.Dyspnea Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside? 1.Code cart 2.Intubation tray 3.Thoracentesis tray 4.Chest tube and drainage system

2.Intubation tray Rationale: The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

2.Ipsilateral paralysis and loss of touch and vibration Rationale: Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord. The remaining options are not assessment findings in this syndrome.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1.Elevate the head of the bed. 2.Examine the rectum digitally. 3.Assess the client's blood pressure. 4.Place the client in the prone position.

3. Assess the clients blood pressure. Rationale: Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? 1.A man who has moderate hypertension 2.A man who has newly diagnosed cataracts 3.A woman who has advanced Parkinson's disease 4.A woman who has early diagnosed Lyme disease

3.A woman who has advanced Parkinson's disease Rationale: Elder abuse includes physical, sexual, or psychological abuse; misuse of property; and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least 1 physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing a side or adverse effect of the medication if which is noted? 1.Dizziness 2.Drowsiness 3.Abdominal pain 4.Lightheadedness

3.Abdominal pain Rationale: Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise. The nurse notifies the primary health care provider if these occur. The signs and symptoms in the remaining options are expected side effects due to the central nervous system-depressant effects of the medication.b

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1.Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia

3.Autonomic dysreflexia Rationale: The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of the seventh thoracic vertebra (T7). Autonomic dysreflexia is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. The data in the question are not associated with the conditions noted in the remaining options.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? 1.Atelectasis and viral infection 2.Bronchoconstriction and stridor 3.Collapse of alveoli and decreased compliance 4.Decreased ciliary action and retained secretions

3.Collapse of alveoli and decreased compliance Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication? 1.Headache 2.Blurred vision 3.Elevated temperature 4.Abdominal distention

3.Elevated temperature Rationale: Dantrolene is a centrally acting muscle relaxant. Malignant hyperthermia is a rare but life-threatening adverse effect that can occur with use of this medication. Therefore, an elevated temperature would alert the nurse to this potential adverse effect.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3.Flaccid paralysis Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder.

A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action? 1.Repeat arterial blood gas testing. 2.Maintain continuous pulse oximetry. 3.Notify the primary health care provider (PHCP). 4.Decrease the amount of oxygen administered.

3.Notify the primary health care provider (PHCP). Rationale: Respiratory failure is defined as a PaO2 of 60 mm Hg or lower. The nurse should notify the PHCP for further prescriptions. Common causes of hypoxemic respiratory failure are pneumonia, pulmonary embolism, and shock. This client should be receiving oxygen. Repeating the arterial blood gases and maintaining continuous pulse oximetry do nothing to correct the problem.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note? 1.PaO2 58 mm Hg, PaCO2 32 mm Hg 2.PaO2 60 mm Hg, PaCO2 45 mm Hg 3.PaO2 49 mm Hg, PaCO2 52 mm Hg 4.PaO2 73 mm Hg, PaCO2 62 mm Hg

3.PaO2 49 mm Hg, PaCO2 52 mm Hg Rationale: Respiratory failure is described as a PaO2 of 60 mm Hg or lower and a PaCO2 of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (PaCO2) from the client's baseline are considered diagnostic.

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1.Notify the neurologist. 2.Loosen tight clothing on the client. 3.Place the client in a sitting position. 4.Check the urinary catheter tubing for kinks or obstruction.

3.Place the client in a sitting position. Rationale: The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Loosening tight clothing and checking the urinary catheter can then be done, and the neurologist can be notified once initial interventions are done.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1.Adhering to the mandatory abuse-reporting laws 2.Notifying the caseworker of the family situation 3.Removing the client from any immediate danger 4.Obtaining treatment for the abusing family member

3.Removing the client from any immediate danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4. Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

Which statement by the nurse indicates a need for further teaching concerning family violence? 1."Abusers use fear and intimidation." 2."Abusers usually have poor self-esteem." 3."Abusers often are jealous or self-centered." 4."Abusers are more often from low-income families."

4."Abusers are more often from low-income families." Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect.

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1."Oh, really? I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends who can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1.Ask the family to deliver the care. 2.Leave the client alone until ready to participate. 3.Advise the client that rehabilitation progresses more quickly with cooperation. 4.Acknowledge the client's anger and continue to encourage participation in care.

4.Acknowledge the client's anger and continue to encourage participation in care. Rationale: Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia)

4.Autonomic dysreflexia (hyperreflexia) Rationale: Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1.A history of diarrhea 2.A flattened abdomen 3.Hyperactive bowel sounds 4.Hematest-positive nasogastric tube drainage

4.Hematest-positive nasogastric tube drainage Rationale: Development of a stress ulcer can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1.Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2.The client has compulsive habits that should be ignored as long as they are not harmful. 3.The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4.Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

4.Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. Rationale: Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the question that would indicate that the client is anorexic or obsessive-compulsive or has a slow metabolism.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1.Keeping the client on a stretcher 2.Logrolling the client onto a soft mattress 3.Logrolling the client onto a firm mattress 4.Placing the client on a bed that provides spinal immobilization

4.Placing the client on a bed that provides spinal immobilization Rationale: Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions.

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program? 1.Sufficiently low water content in the stool 2.Low intestinal roughage that promotes easier digestion 3.Constriction of the anal sphincter based on voluntary control 4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord Rationale: The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.