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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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The nurse is reinforcing teaching to the parents of a hospitalized 3-month-old about separation anxiety. The nurse notices that the parents still seem concerned about leaving the infant while they work. Which statement by one of the parents indicates that the teaching has been effective?
- A. At this age, my baby will not cry because we are leaving.
- B. I know my baby will feel abandoned when we leave.
- C. My baby is too young to sense my anxiety about leaving.
- D. My baby understands that we will return later in the day.
Correct Answer: C
Rationale: Infants at 3 months (C) do not yet exhibit separation anxiety and cannot sense parental anxiety. Crying (A), feeling abandoned (B), and understanding return (D) occur later in development.
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order.
- B. Administer the medications.
- C. Administer them separately.
- D. Contact the pharmacy.
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly prescribed together for hypertension, as lisinopril is an ACE inhibitor that reduces blood pressure, and furosemide is a diuretic that reduces fluid volume. There is no contraindication for administering them concomitantly, so answer A is incorrect. Administering them separately is unnecessary, so answer C is incorrect. Contacting the pharmacy is not needed unless there is a supply issue, so answer D is incorrect.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
The nurse is caring for a client with schizophrenia. The client appears anxious and states, 'The voices are bad today; they sound so angry with me.' Which of the following responses would be most appropriate for the nurse to make?
- A. You should not listen to the voices.
- B. Remember that the voices are not real. Tell the voices to go away.
- C. What are the voices saying to you?
- D. That sounds frightening. Would you like medication to help you feel less anxious?
Correct Answer: D
Rationale: Acknowledging the client's fear and offering medication (D) is therapeutic and addresses anxiety. Dismissing voices (A, B) or probing content (C) may increase distress or reinforce delusions.
The practical nurse (PN) is assisting with care for a 1-day-old client who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the registered nurse to develop the plan of care, which intervention should the PN include?
- A. Avoid giving the newborn a pacifier
- B. Position the newborn supine after feeding
- C. Stimulate the newborn with light regularly
- D. Swaddle and gently rock the newborn
Correct Answer: D
Rationale: Swaddling and rocking (D) soothe a newborn with neonatal abstinence syndrome due to maternal hydrocodone use. Pacifiers (A) are helpful, supine positioning (B) is for safety but not soothing, and stimulation (C) may worsen irritability.