A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?
a. Place patient in flat position and check temperature
b. Administer oxygen and check oxygen saturation
c. Place on side and check for leg swelling
d. Sit upright and check blood pressure
ANS: D
These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.
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The health care organization has made a conscious effort to provide linguistically appropriate services to its predominantly Hispanic population, incorporating within its staff members from different Spanish-speaking countries of Latin America. Which cultural care concept is this organization implementing?
A. Language proficiency B. Cultural competence C. Cultural sensitivity D. Cultural appropriateness
The nurse discusses the immune response with a group of older adults. Which of the following is one of the factors that contributes to the severity of infectious diseases in the older adult population?
A) Loss of collagen leading to thin skin B) Inability to tolerate antibiotic therapy C) Localized reduction in T lymphocytes D) Increased incidence of hospitalizations
The nurse manager for a medical-surgical nursing unit is talking to a group of nursing students. The nurse manager is explaining the types of nursing research studies that are conducted on the unit. Which statement by the students indicates understanding
A) "Nursing research does not include nursing education." B) "Nursing research does not include the study of nurses themselves." C) "Nursing research impacts nursing by adding knowledge and changing nursing practice." D) "Nursing research is used to enhance medical treatment."
The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings(s) has/have aroused her suspicion? Choose all that apply
1) Disorientation 2) Restlessness 3) Hallucinations 4) Depression