A client receiving care for a spinal cord injury complains of a pounding headache, blurred vision, and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take?
1. Administer pain medication.
2. Position the client on the left side.
3. Turn off the lights and decrease the noise in the room.
4. Check the bladder for distension.
4
The symptoms suggest autonomic hyperreflexia, a medical emergency. The client should be checked for a distended bladder and be prepared for catheterization. Pain medication, positioning, or reducing environmental stimuli will not treat the underlying cause of autonomic hyperreflexia.
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The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
The educator of a geriatric, subacute medical unit in a hospital is oriented new staff and teaching orientees' strategies for communicating with older adults with impaired hearing. Which of the following teaching points is most justifiable?
A) "Speak slowly and directly to these clients." B) "Avoid complex or abstract ideas when you're talking." C) "Increase the volume of your speech as much as possible." D) "Choose simple, short words to minimize confusion."
The nurse caring for a postpartum client would consider the nursing diagnosis of ineffective individual coping when the client demonstrates which behavior?
A) Reading material on care of a newborn B) Lying in bed, lights dim, and refusing to spend time with the baby C) Cuddling the new infant D) Talking with friends and family on the phone
Diagnostic procedures are being performed on a female patient who may have systemic lupus erythematosus (SLE)
Which findings would the nurse evaluate as supporting this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Elevated LE prep 2. Hematuria 3. Negative anti-SM antibody 4. C3 complement protein of 94 mg/dL 5. Sodium 138