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Question 1 of 5

A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?

Correct Answer: D

Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.

Question 2 of 5

A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?

Correct Answer: A

Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.

Question 3 of 5

When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?

Correct Answer: A

Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.

Question 4 of 5

The nurse is reinforcing information on dietary management to a group of clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?

Correct Answer: B

Rationale: Baked bean chili with brown rice and salad provides fiber, lean protein, and vegetables, balancing blood sugar. Fries and hamburger buns are higher in simple carbs, less ideal for diabetes control.

Question 5 of 5

The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:

Correct Answer: B

Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.

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