The patient is treated for muscle spasms following a spinal cord injury. What is the best outcome for this patient?
1. Patient will have stabilized vital signs.
2. Patient will have an improved self-concept.
3. Patient will sleep without pain.
4. Patient will have increased bladder tone.
3
Rationale 1: Stabilization of vital signs is not an expected effect of this medication.
Rationale 2: Relief of muscle spasms may help with self-concept, but this is not a direct effect of the drug.
Rationale 3: Decreasing muscle spasms will help prevent pain that can interfere with sleep.
Rationale 4: This medication relaxes muscles, but it will not increase bladder tone.
Global Rationale: Decreasing muscle spasms will help prevent pain that can interfere with sleep. This medication relaxes muscles, but it will not increase bladder tone. Stabilization of vital signs is not an expected effect of this medication. Relief of muscle spasms may help with self-concept, but this is not a direct effect of the drug.
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The nurse is reviewing crutch-walking with the client prior to discharge. The nurse concludes that the client needs further instruction if the client states which of the following?
1. "Each step I take with crutches should feel comfortable to me." 2. "I need to inspect the crutch tips and replace them if they are worn." 3. "I should pad the crutches well to protect my armpits." 4. "I should wear running shoes to support my feet."
The client with sickle cell anemia has had an erection for longer than 4 hours. How does the nurse intervene?
a. Administer a diuretic to increase urine output. b. Attempt to relieve pressure by catheteriz-ing the client. c. Document the finding and reassess in 4 hours. d. Notify the health care provider and pre-pare to give meperidine (Demerol).
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action?
a. Place the client in a high Fowler's posi-tion. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.
The nurse is reviewing instructions for a patient recovering from a D&C. What should the nurse emphasize when teaching this patient?
Select all that apply. 1. Avoid heavy lifting for several days. 2. Avoid using tampons for 2 weeks. 3. Rest for several days after the procedure. 4. Expect the next menstrual period to be early. 5. Expect vaginal bleeding to be bright red and very heavy.