N-Clex Practice Flashcards
Because of prolonged bile drainage from a T-tube, a client may develop symptoms related to a lack of fat-soluble vitamins such as:
easy bruising
*Vitamin K, a precursor for prothrombin, cannot be absorbed without bile.
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet?
Vitamin B 12
* Vegans do not consume any animal products and therefore would most likely be lacking in a vegan diet.
Which clinical manifestation would the nurse assess in the client with a T-12 spinal cord injury (SCI) who is experiencing spinal shock?
Flaccid paralysis below the waist
* Spinal shock is associated with an SCI. It is a sudden depression of a reflex activity, a loss of sensation, and flaccid paralysis below the level of the injury.
The nurse is caring for a client who has a C-6 vertebral fracture and is using Crutchfield tongs with 2-pound weights. Which data would the nurse expect the client to exhibit?
The client has 2+ deep tendon reflexes in the lower extremities
* The spinal cord has not been injured; therefore, responses, and reflexes should be intact. The Crutchfield tongs ensure that the cervical spine remains in alignment.
The rehabilitation nurse caring for the young client with a T-12 SCI is developing the nursing care plan. Which priority intervention should the nurse implement?
Insert a rectal stimulant at the same time every morning.
* The client’s bowel and bladder functions must be adressed; therefore, administering a daily rectal stimulant will ensure a daily bowel movement.
The nurse is caring for a client with a C-6 SCI in the neurological intensive care unit. Which nursing intervention should be implemented?
Maintain the client’s ice saline infusion.
* Current treatment options that have proven efficacy in treating SCI is to decrease inflammation and edema by lowering the body temperature with ice saline infusions.
A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nuse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of:
Pork
* The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin.
The male client with a C-6 SCI tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the clinic nurse implement?
Determine when and how much the client last urinated.
* The cause of the pounding headache is most likely autonomic dysreflexia, a result of exaggerated autonomic responses to stimuli. An elevated blood pressure would confirm this. The most common cause of autonomic dysreflexia is a full bladder.
The client with a T-1 SCI complains of lightheadedness and dizziness when the head of the bed is elevated. The client’s B/P is 84/40. Which action should the nurse implement first?
Lower the client’s head of bed immediately.
* The blood pressure tends to be very unstable and low for clients with an SCI of T-6 or above, and slight elevations of the head of the bed can cause profound drops in the client’s vital signs.
The nurse walks into the room and notes the male client is lying supine, and the entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
Turn the client on his side.
* Placing the client on his side helps keep the airway patent; therefore, it is the first intervention. Airway is priority.
The client newly diagnosed with epilepsy who works in an office asks the nurse, “What can I do to prevent having seizures?” Which statement is the nurse’s best response?
“Ask your supervisor to have someone else make copies.”
- Flashing lights, such as occur with a copying machine, can evoke a seizure and should be avoided; other causes of seizures include stress, fatigue, and alcohol intake.
Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?
“My menstrual cycle may affect my sezure disorder.”
- Because of the fluctuations in hormones that alter the excitability of neurons in the cerebral cortex, an increase in seizure frequency may occur during menses.
The clinic nurse is checking diagnostic test results. Which diagnostic test result would warrant notifying the client immediately?
The client who is diagnosed with epilepsy who has a phenytoin (Dilantin) level of 28 mcg/dL.
* The therapeutic Dilantin level is 10-20 mcg/dL requires notifying the client.
The nurse and a UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
The UAP places the gait belt under the client’s axilla prior to ambulating.
* The gait belt should be around the waist because this is the client’s center of gravity.
The client is diagnosed with chronic atrial fibrillation has experienced a transient TIA. Which discharge instruction should the nurse implement?
Obtain International Normalized Ratio (INR) routinely.
* An oral anticoagulant, warfarin (Coumadin), will be prescribed to help prevent the formation of thrombi in the atrium secondary to atrial fibrillation. The thrombi can become embolic, which may cause a TIA. The INR is the laboratory value used to determine therapeutic oral anticoagulant levels.
