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NUR 1025C’FinalSG/ Florida State College at Jacksonville LATEST
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NUR 1025C’FinalSG/ Florida State College at Jacksonville LATEST
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NUR 1025C’FinalSG/ Florida State College at Jacksonville LATEST1.Autonomic dysreflexia happens with spinal cord
injuries some causes include bladder distention, tight
clothing, increased room temperature and fecal
impaction. If a patient comes in and their BP is high,
they have a flushed face & blurred vision one of the
things you will do is check their bladder for distention.
A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm
Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take
first?
a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for
distention.
d. Administer a prescribed beta blocker.
ANS: C
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention,
tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience
neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other
actions would not be appropriate.
EXTRA: The nurse is caring for a patient with spinal cord injury (SCI). Which
interventions does the nurse use to target and prevent a potential SCI complication
of Autonomic Dysreflexia? (Select all that apply)
a. Frequently perform passive ROM exercises.
b. Loosen or remove any tight clothing.
c. Monitor stool output and maintain a bowel program.
d. Keep the patient immobilized with neck or back braces. e. Monitor urinary output and
check for bladder distention.
ANS: B,C,E
2. Hepatitis A, fecal contamination, food and water.
After teaching a client who has plans to travel to a non-industrialized country, the
nurse assesses the client's understanding regarding the prevention of viral hepatitis.
Which statement made by the client indicates a need for additional teaching?
,NUR 1025C’FinalSG/ Florida State College at Jacksonville LATEST
a. "I should drink bottled water during my travels."
b. "I will not eat off another's plate or share utensils." c. "I should eat plenty of fresh
fruits and vegetables." d. "I will wash my hands frequently and thoroughly."
ANS: C
The client should be advised to avoid fresh, raw fruits and vegetables because they
,NUR 1025C’FinalSG/ Florida State College at Jacksonville LATEST
can be contaminated by tap water. Drinking bottled water, and not sharing plates,
glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.
3.A patient is experiencing bradycardia with
hypotension and dizziness, give Atropine to reverse
bradycardia.
Which drug for symptomatic bradycardia does the nurse prepare to a minister to a
patient with a bradydysrhythmia?
a. Epinephrine b. Atropine
c. Calcium
d. Lidocaine
ANS: B
The patient with a spinal cord injury has a heart rate of 42/minute. Which drug does
the nurse expect to administer?
a. Methylprednisolone b. Dextran
c. Atropine
d. Dopamine
ANS:C
4. If someone is diabetic what is the primary
manifestation? Polyuria, check urine output.
5. A person comes into the ED bleeding everywhere, put on your PPE first.
A trauma client with multiple open wounds is brought to the emergency department
in cardiac arrest. Which action should the nurse take prior to providing advanced
cardiac life support? a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
, NUR 1025C’FinalSG/ Florida State College at Jacksonville LATEST
ANS: B
Someone has cirrhosis, ascites and edema, what lab
6.
will you look at? Albumin.
A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a
reduced glomerular filtration rate and is not undergoing dialysis. Which result would
give the nurse the most concern?
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