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When planning to move a person with a possible spinal cord injury, the nurse should direct the team to:
- A. Limit movement of the arms by wrapping them next to the body.
- B. Move the person gently to help reduce pain.
- C. Immobilize the head and neck to prevent further injury.
- D. Cushion the back with pillows to ensure comfort.
Correct Answer: C
Rationale: Immobilizing the head and neck prevents exacerbation of a spinal cord injury during movement.
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A sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan with the client that will focus on participating in which of the following activities? Select all that apply.
- A. Aerobic activity
- B. Strength training
- C. Weight control
- D. Stress management
Correct Answer: A,C,D
Rationale: Rationales: A) Aerobic activity (e.g., walking) improves circulation and reduces clot recurrence. C) Weight control decreases venous pressure and clot risk. D) Stress management reduces sympathetic activation, aiding vascular health. B) Strength training is less critical for clot management and may be contraindicated initially.
What is the nurse's best action for a client with a suspected stroke and aphasia?
- A. Speak loudly.
- B. Use simple phrases.
- C. Write all instructions.
- D. Avoid communication.
Correct Answer: B
Rationale: Using simple phrases supports communication in stroke patients with aphasia.
A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The nurse should base the response on the knowledge that there was:
- A. A decrease in the blood flow through the kid-
- B. An obstruction of urine flow from the kidneys.
- C. A blood clot formed in the kidneys.
- D. A structural damage to the kidney resulting in acute tubular necrosis.
Correct Answer: A
Rationale: Decreased renal blood flow from shock post-myocardial infarction reduces kidney perfusion, leading to acute renal failure.
What is the nurse's best response to a client with MS experiencing fatigue?
- A. Limit all activities.
- B. Schedule rest periods.
- C. Increase fluid intake.
- D. Avoid all exercise.
Correct Answer: B
Rationale: Scheduling rest periods helps manage fatigue while supporting activity in multiple sclerosis.
A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
- A. The lung has fully expanded.
- B. The lung has collapsed.
- C. The chest tube is in the pleural space.
- D. The mediastinal space has decreased.
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.