Practice Question
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
Answer Choices:
Correct Answer:
An acutely distended bladder.
Rationale:
♦ Autonomic dysreflexia in clients with spinal cord injuries above T6, such as C7, is often triggered by bladder distention, bowel impaction, or skin irritation.
♦ It is a life-threatening hypertensive emergency caused by an exaggerated sympathetic response.
♦ Identifying and relieving the precipitating cause—commonly a full bladder—should be done immediately to prevent complications.
Want to practice more questions like this?
This question is from RN-Hesi Medical Surgical Exam IV which contains 48 questions.
More Questions from This Exam
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Answer Choices:
A. Auscultate lungs for unequal breath sounds.
B. Continue to monitor the drainage system.
C. Lift and clear drainage from the chest tube.
D. Inspect the tube insertion site for leaking.
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?
Answer Choices:
A. Sputum culture positive for Mycobacterium tuberculosis.
B. Hemoccult test on sputum collected from hemoptysis.
C. Chest x-ray or computed tomography (CT).
D. Positive purified protein derivative (PPD) skin test.
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 µg/dL (157.1 µmol/dL). Which action should the nurse take?Reference Range:Ammonia [10 to 80 µg/dL (6 to 47 µmol/L)]
Answer Choices:
A. Hold the next dose of lactulose.
B. Continue the prescribed dose of lactulose.
C. Replace total volume voided with oral or IV fluids.
D. port the number of diarrhea stools to the healthcare provider (HCP).
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?
Answer Choices:
A. Severe abdominal cramps and diarrhea after eating spicy foods.
B. Frequent use of chewable and liquid antacids for indigestion.
C. Upper mid abdominal pain described as gnawing and burning.
D. Marked loss of weight and appetite over the last 3 or 4 months.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi MedSurg
- Answer Choices: 4
Was this question helpful?
0/5 average rating
(0 votes)