The nurse teaches a patient that autonomic dysreflexia can be triggered by a:
a. loud sound.
b. distended bladder.
c. leg cramp.
d. sudden chilling.
B
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.
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The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse?
1. Resetting the pump to resume infusion 2. Discontinuing the client's IV access and restarting in a different area 3. Assessing the client's IV site and the tubing for kinks or closed roller clamps 4. Asking the client if the pump has been tampered with in any way
The hospital nurses, after attending a conference on nursing burnout, discuss among themselves strategies to use when working with families of dying children. Which of the following would be helpful? Select all that apply
1. Planning the child and family's care alone as the primary nurse 2. Participating in team decisions regarding the dying child's plan of care 3. Declining the family's invitation to attend the child's funeral 4. Participating in a mentoring relationship with experienced hospice nurses 5. Participating in support groups with mental health professionals
The nurse explains that because of the scant amount of urine excreted and the high amount of albumin in the urine, the urine of a child with nephrosis will be:
a. Grossly bloody b. Foul smelling and light c. Dark and frothy d. Light and clear
The nurse learns that a client from a different country and culture was married to her first cousin before moving to the United States. The couple is expecting their first child in 4 months. What should the nurse consider when counseling this client?
1. Birth control 2. Carrier testing 3. Pregnancy termination 4. Legal issues in the United States