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The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?
- A. MRIs are loud but there will not be any invasive procedure done.'
- B. You’re scared. Tell me about what is scaring you.'
- C. This is the least thing to be scared about—there will be worse.'
- D. I can call the MRI tech to come and talk to you about the scan.'
Correct Answer: B
Rationale: Reflecting the client’s fear (B) encourages expression of concerns, fostering therapeutic communication. Other options provide information (A, D) or minimize feelings (C).
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The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has 'started using again.' Which action should the nurse implement?
- A. Tell Client A the nurse cannot discuss Client B with him.
- B. Find out how Client A got this information.
- C. Inform the HCP that Client B is using again.
- D. Get in touch with Client B and have the client come to the clinic.
Correct Answer: D
Rationale: Allegations of relapse require direct assessment. Contacting Client B (D) allows the nurse to evaluate the situation respectfully. Discussing Client B with Client A (A) or probing Client A (B) breaches confidentiality, and informing the HCP (C) is premature without verification.
Which home care suggestion is best for promoting the mobility of the client with a spinal cord injury?
- A. Rent or buy a conventional hospital bed.
- B. Build a wheelchair ramp to the door.
- C. Apply for a handicapped parking sticker.
- D. Provide a raised toilet seat with grab bars.
Correct Answer: B
Rationale: A wheelchair ramp enhances home accessibility, significantly improving mobility for a client with a spinal cord injury.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.
- A. Occupational Therapist (OT).
- B. Physical therapist (PT).
- C. Registered dietitian (RD).
- D. Rehabilitation physician.
- E. Social Worker (SW).
- F. Patient care tech (PCT).
Correct Answer: A,B,D,E
Rationale: OT (A) and PT (B) address functional and mobility needs, the physician (D) oversees medical care, and the social worker (E) coordinates resources. Dietitian (C) and PCT (F) are less critical for case conferences.
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client’s spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?
- A. “Plasmapheresis removes excess fluid from the bloodstream.”
- B. “Plasmapheresis will increase the protein levels in the blood.”
- C. “Plasmapheresis removes circulating antibodies from the blood.”
- D. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”
Correct Answer: C
Rationale: Aquapheresis or dialysis, not plasmapheresis, will remove excess fluid from the blood. Plasmapheresis does not increase protein levels in the blood. Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client. Plasmapheresis does not involve infusing lipoproteins.