A patient with an SCI begins to have seizures, and the blood pressure (BP) rises rapidly to 210/160 mm Hg. Which is the third indicator of the syndrome of autonomic dysreflexia?
a. Profuse vomiting
b. Hives on face and neck
c. Excessive urine output
d. Bradycardia
D
Bradycardia, hypertension, and seizure are the three signs of autonomic dysreflexia.
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The patient is exhibiting poor gas exchange. Four factors influence gas exchange across the alveolar membrane. What condition related to the four factors could be interfering with gas exchange?
A) Oxygen at 100% B) 35% of the alveoli are filled with fluid. C) Oxygen delivered under pressure D) Alveolar membranes are 0.3 microns thick.
The patient asks why the nurse is asking questions about her mother's obstetrical history. Which rationale for this questioning should the nurse provide?
1. "If your mother smoked while she was pregnant with you, your risk of lung cancer is higher.". 2. "Use of medications to prevent miscarriage may have an impact on your health.". 3. "The government wants to know for a genetic study.". 4. "If your mother had bleeding after delivery, you should avoid aspirin if you become pregnant.".
The client receives oral nystatin (Mycostatin) suspension for an oral candidiasis infection. She tells the nurse she cannot continue to "swish and swallow" because her nausea is too great. What is the best response by the nurse?
1. "I will ask your doctor if a pill form can be substituted." 2. "Try drinking a 7-Up after you swallow the medication." 3. "It is all right to swish the medication and then spit it out." 4. "You can take a phenergan suppository before the nystatin (Mycostatin)."
The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN?
a) Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format b) Giving the ordered dose of Narcan and evaluating the response to therapy c) Monitoring the respiratory status for the first 30 minutes d) Applying oxygen per nasal cannula as ordered