Nursing Elites

1. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

• A. "I should raise him to a sitting position."?
• B. "I should check for a fecal impaction."?
• C. "I should look for a kink in the urinary catheter tubing."?
• D. "I should observe whether symptoms worsen."?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

2. A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?

• A. Leaving articles about judgmental opinions in the nurses' report room
• B. Reporting the nurses' comments to administration
• C. Discouraging the judgmental comments
• D. Ignoring the comments made about the client

Correct answer: C

Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as 'uncooperative' or 'difficult.' When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not be addressed. Leaving articles about judgmental opinions in the nurses' report room indirectly addresses the issue, but there is no guarantee that the staff will read them. Reporting the nurses' comments to administration does not directly address the issue. The best approach for the nurse is to discourage judgmental comments directly with the staff members. Since this action is not provided in the options, discouraging judgmental comments is the most appropriate way to manage this concern.

3. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?

• A. sudden onset of headache
• B. flushed face
• C. hypotension
• D. nasal congestion

Correct answer: C

Rationale: Autonomic dysreflexia is characterized by a sudden onset of symptoms due to an overactive autonomic nervous system. Hypotension is not indicative of autonomic dysreflexia; instead, hypertension is a hallmark sign. Therefore, hypotension is the correct answer. Flushed face, sudden onset of headache, and nasal congestion are classic symptoms of autonomic dysreflexia caused by a noxious stimulus below the level of the spinal cord injury. These symptoms result from the body's attempt to regulate blood pressure when the normal feedback loop is interrupted.

4. An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?

• A. Inability to turn, cough, and breathe deeply
• B. Inability to communicate pain
• C. Inability to ambulate freely
• D. Inability to use a bedside commode

Correct answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain. Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.

5. When removing a client's gown with an intravenous line, what should the nurse do?

• A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
• B. cut the gown with scissors
• C. thread the bag and tubing through the gown sleeve, keeping the line intact
• D. temporarily disconnect the tubing from the intravenous container and thread it through the gown

Correct answer: C

Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.

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