Question

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?

Answer 1

Correct Answers:

The client’s bladder becomes distended.

Rationale :

💧Bladder distention is the most common trigger for autonomic dysreflexia in clients with spinal cord injuries at T6 or above, including T4.

⚠️This leads to an exaggerated autonomic response resulting in hypertension, bradycardia, and other symptoms.

💥Severe headache, nasal congestion, and elevated blood pressure are signs of autonomic dysreflexia, not causes.

🛑Recognizing and removing the noxious stimulus, like a full bladder, is key to resolving the episode.

📌Core Message

In clients with T6 or higher spinal injuries, bladder distention can trigger autonomic dysreflexia.

Answer 2

Correct Answers:

Aspirate the clients stomach contents.

Rationale :

🧪Checking gastric residuals before feeding ensures proper placement and delayed gastric emptying, which helps prevent aspiration pneumonia.

🛑Labeling, positioning the bag, and warming the formula are important but do not ensure patient safety during initial steps.

📉Aspirating is a priority action to assess the client’s tolerance and reduce the risk of complications.

🔍This step is always done before initiating or continuing enteral feeding via NG tube.

📌Core Message

Always aspirate stomach contents first before initiating enteral feeding to assess for tolerance and safety.

Answer 3

Correct Answers:

Stable angina can be relieved with rest and nitroglycerin.

Rationale :

💊Stable angina is typically relieved with rest or nitroglycerin, while MI pain persists despite such measures.

⏱️MI pain lasts longer than 30 minutes, is more severe, and may be associated with nausea, diaphoresis, and dyspnea.

🏃MI can occur at rest or with minimal exertion, unlike stable angina which is predictably triggered by activity.

🩺Understanding these differences allows for early differentiation and prompt treatment.

📌Core Message

Stable angina is usually relieved by rest and nitroglycerin, unlike the persistent pain of myocardial infarction.

Answer 4

Correct Answers:

Use of alcohol

Rationale :

🍷Chronic alcohol consumption is the leading cause of chronic pancreatitis, leading to inflammation and fibrosis of pancreatic tissue.

🔥This disrupts enzyme production and digestion, resulting in chronic abdominal pain and malabsorption.

⚠️Weight gain and occupational exposures are not primary causes; instead, malnutrition and weight loss are more common.

🍽️Pain relief with food is seen in peptic ulcers, not pancreatitis.

📌Core Message

Alcohol abuse is the most common cause of chronic pancreatitis, leading to progressive pancreatic damage.

Answer 5

Correct Answers:

Dyspnea

Rationale :

💁‍♂️Dyspnea (difficulty breathing) is a hallmark sign of left-sided heart failure, resulting from pulmonary congestion due to left ventricular dysfunction.

💦This causes fluid to back up into the lungs, leading to shortness of breath and crackles.

🥴Anorexia, weight gain, and abdominal distension are more indicative of right-sided heart failure.

💡Recognizing pulmonary symptoms helps detect early left-sided cardiac dysfunction.

📌Core Message

Dyspnea is a key indicator of left-sided heart failure due to pulmonary congestion.

Answer 6

Correct Answers:

Heparin

Rationale :

🩸Heparin is the anticoagulant of choice for treating pulmonary embolism, as it prevents further clot propagation and allows the body to naturally dissolve the embolus.

💊It acts quickly and is often followed by oral anticoagulants for long-term therapy.

🚫Atropine, furosemide, and dexamethasone are not appropriate for initial PE management.

⚠️PE is life-threatening and requires prompt anticoagulation to prevent complications.

📌Core Message

Heparin is administered to manage pulmonary embolism by preventing further clot formation.

Answer 7

Correct Answers:

Fatty stools

Rationale :

💩Fatty stools (steatorrhea) occur when the common bile duct is obstructed, preventing bile from reaching the intestines and leading to fat malabsorption.

🟡Bile is essential for fat digestion, and its absence results in pale, greasy, and foul-smelling stools.

🔍Tenderness would occur in the right upper quadrant, not the left.

🧪Urine often becomes dark, not pale, due to increased bilirubin levels.

📌Core Message

Fatty stools result from bile duct obstruction, causing fat malabsorption in conditions like cholecystitis.

Answer 8

Correct Answers:

Severe pain

Rationale :

🧨Renal calculi typically cause sudden, severe, and colicky flank pain, often radiating to the groin.

💥This pain is due to ureteral spasms as the stone passes through the urinary tract.

📉Bradycardia and bradypnea are not common findings — pain usually causes tachycardia and restlessness.

🌙Nocturia is not a classic presentation during acute stone passage.

📌Core Message

Severe flank or abdominal pain is the primary symptom of renal calculi due to urinary tract obstruction.

Answer 9

Correct Answers:

Hypophosphatemia

Rationale :

🧫Refeeding syndrome results in a sudden shift of electrolytes, especially phosphate, into cells, leading to hypophosphatemia.

⚠️This can cause muscle weakness, respiratory failure, and cardiac arrhythmias if untreated.

📉Clients who are malnourished or in a catabolic state are at greatest risk when starting nutrition.

💊Monitoring electrolytes like phosphate, potassium, and magnesium is essential during nutritional repletion.

📌Core Message

Hypophosphatemia is the hallmark lab finding in refeeding syndrome, requiring close monitoring and correction.

Answer 10

Correct Answers:

Decreased ammonia levels

Rationale :

🧠Lactulose treats hepatic encephalopathy by reducing ammonia levels, improving mental status and neurological function.

🧪It works by acidifying the colon, trapping ammonia and promoting excretion in stool.

🚫Its primary purpose is not to relieve constipation or reduce liver enzymes.

🤕Ammonia buildup is the direct cause of confusion and altered mental status in hepatic encephalopathy.

📌Core Message

Lactulose is effective in hepatic encephalopathy when it lowers serum ammonia levels.

1 :
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?

2 :
A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

3 :
A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?

4 :
A nurse is obtaining a health history for a client with chronic pancreatitis. Which of the following indicates the primary cause of the client's condition?

5 :
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

6 :
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

7 :
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

8 :
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?

9 :
A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?

10 :
The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?

1 : A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?

2 : A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

3 : A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?

4 : A nurse is obtaining a health history for a client with chronic pancreatitis. Which of the following indicates the primary cause of the client's condition?

5 : A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

6 : A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

7 : A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

8 : A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?

9 : A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?

10 : The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?

1 :
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?

2 :
A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

3 :
A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?

4 :
A nurse is obtaining a health history for a client with chronic pancreatitis. Which of the following indicates the primary cause of the client's condition?

5 :
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

6 :
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

7 :
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

8 :
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?

9 :
A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?

10 :
The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?