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The nurse is assisting with the care of a client who sustained a cervical spinal cord injury 1 hour ago and has paralysis in all four extremities. Which of the following actions would be a priority for the nurse to take?
- A. Reposition the client every 2 hours.
- B. Monitor the client for autonomic dysreflexia.
- C. Check the client's respiratory status frequently
- D. Perform passive range-of-motion exercises every 4 hours.
Correct Answer: C
Rationale: Respiratory status (C) is the priority in acute cervical spinal cord injury due to risk of respiratory failure. Repositioning (A), dysreflexia monitoring (B), and exercises (D) are secondary.
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An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:
- A. Strep throat
- B. Epiglottitis
- C. Laryngotracheobronchitis
- D. Bronchiolitis
Correct Answer: B
Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.
The nurse in a college health clinic is teaching the male students testicular self-examination. Which statement made by one of the young men indicates a need for more teaching?
- A. I should do a testicular self-examination every month.'
- B. When I am taking a shower is a good time to do the self-exam.'
- C. If I feel any lumps, I should report it to the physician.'
- D. Testicular cancer is usually found in older men.'
Correct Answer: D
Rationale: Testicular cancer primarily affects younger men (15–35 years), not older men, indicating a need for more teaching. Monthly exams, shower timing, and reporting lumps are correct.
The nurse observes a client who is walking with a cane. Which observation indicates that the client is walking appropriately?
- A. The client holds the cane on the affected side and moves it forward with the affected leg.
- B. The client holds the cane on the affected side and moves it forward with the unaffected leg.
- C. The client holds the cane on the unaffected side and moves it forward with the affected leg.
- D. The client holds the cane on the unaffected side and moves it forward with the unaffected leg.
Correct Answer: C
Rationale: Holding the cane on the unaffected side and moving it with the affected leg provides optimal support and balance, coordinating strength with the weaker side.
The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?
- A. Activate the rapid response team.
- B. Approach the client calmly and acknowledge the client's feelings.
- C. Escort other clients away from the area.
- D. Inform the client that the action was dangerous and unacceptable.
Correct Answer: C
Rationale: Ensuring safety by escorting others away (C) is the priority. Rapid response (A) may be premature, approaching the client (B) risks escalation, and informing of consequences (D) is secondary.
The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.