A patient is brought to the emergency department after being involved in a motorcycle accident. He is found to have a T1 spinal cord injury. What is this patient at increased risk for because of his injury?
A) Pulmonary edema
B) Pulmonary emboli
C) Decreased PaCO2
D) Increased vital capacity
Ans: A
Feedback: With injuries to the cervical and upper thoracic spinal cord, innervation to the major accessory muscles of respiration is lost and respiratory problems develop. These include decreased vital capacity, retention of secretions, increased PaCO2 levels, decreased oxygen levels, respiratory failure, and pulmonary edema.
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An RN who has been a nurse for 10 years is precepting a novice RN. The novice is having difficulty prioritizing client care. What should the RN tell the novice about the principles of prioritizing care?
A. The nursing process B. Virchow's triad C. Client requests D. Maslow's hierarchy of needs
A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?
a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse
The nurse is performing a physical exam for a 9-year-old boy who complains of a stiff neck and pain in his arms and legs. He has never been vaccinated for polio. Which of the following assessment findings would suggest the child has polio?
A) Swelling in the neck B) Confusion and anxiety C) Positive Kernig's sign D) Conjunctivitis
The nurse would realize that outcomes for the diagnosis Ineffective Health Maintenance have been partly met when the client (Select all that apply)
a. begins and maintains an exercise program. b. has ideas for incorporating medications into lifestyle. c. helps design a diet modification. d. says he/she will comply with whatever plan the nurse makes. e. shows the nurse the correct way to take the pulse.