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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 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 3 of 5

Which situations would prompt the health care team to use the client’s advance directive to make a decision regarding care? Select all that apply.

Correct Answer: B,D

Rationale: Advance directives guide care when clients cannot communicate decisions, as with a GCS of 3 (unconscious) or aphasia from hemorrhage. Paraplegia, religious refusal, and ventilator use in an oriented client do not impair decision-making capacity.

Question 4 of 5

A 52-year-old woman who has thyroid cancer is treated with radioactive iodine (Iodotope). What should be included in the nursing care plan following administration of the drug? Select all that apply.

Correct Answer: B,D,E,F

Rationale: Radioactive iodine requires isolation in a single room, limited contact (30 minutes/shift), separate sleeping for 7 days, and reporting symptoms like fatigue or weight gain (hypothyroidism). NPO or urine storage are not standard.

Question 5 of 5

A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:

Correct Answer: A

Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.

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