Answer to Question 1
B
Feedback:
The nurse should be aware that the sudden onset of hypertension in clients with autonomic dysreflexia causes seizures or strokes. Autonomic dysreflexia is characterized by a sudden and dangerous elevation of blood pressure owing to autonomic response to various stimuli. A sudden onset of hypertension may not result in chills and severe headache, respiratory distress, or visual disturbances.
Answer to Question 2
A
Feedback:
First-intention healing occurs in wounds with minimal tissue loss, such as surgical incisions or wounds sutured soon after injury. Second-intention healing occurs with tissue loss, such as lacerations, burns, and pressure ulcers. Third-intention healing occurs when there is a delay in the time between the injury and wound closure. It occurs after surgery when there is an infection or in a large open wound when the wound is closed later. There is no fourth-intention healing.
A physician is performing a colonoscopy on a client and viewing the internal structures of the colon
Example of simplified note for one-time client.
A hot stone placed under the client’s neck.
Positioning the client
The nurse begins the general survey