When changing the position of a patient with a spinal cord injury at T4, the nurse should recognize that what symptom is an indication of an episode of autonomic dysreflexia?
a. Nausea
b. Pallor
c. Goose bumps
d. Dizziness
ANS: C
Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the skin, and a severe pounding headache.
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The patient has just had a transvenous cardiac pacemaker lead inserted into the subclavian vein. What patient symptom, if found by the nurse, would most indicate a possible complication unique to the use of the subclavian vein?
A) Persistent hiccups at the same rate as the pacemaker's set rate B) Sudden respiratory distress, hypoxia, and hypotension C) Persistent premature ventricular complexes seen on cardiac monitor D) Oversensing, undersensing, or failure to capture
When working with the community to develop plans to meet the needs of people with disabilities, the community health nurse reviews the statistics involving individuals with disabilities
Which of the following would the nurse identify as accurately reflecting the number of persons with ongoing disability? A) 10 million people, less than 5% of the U.S. population B) 27 million people, about 10% of the U.S. population C) 54 million people, about 20% of the U.S. population D) 150 million people, almost 50% of the U.S. population
Which core function supports the belief that all Americans should receive basic health care services?
a. Assessment b. Assurance c. Policy development d. Advocacy
A client asks the nurse about the characteristics of absence seizures. Which explanation should the nurse provide the client?
A. "Absence seizures are basically the same kind of seizures as grand mal, but they are less frequent." B. "This type of seizure is characterized by staring into space for a few seconds." C. "Absence seizures are characterized by twitching of the arms and legs." D. "This type of seizure is similar to drop attacks."