A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?

Correct Answer: B

Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.

Correct Answer: C

Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult. A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony. B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage. D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.

Correct Answer: B

Rationale: The correct answer is B: "The medication will help you think more clearly." This is the most appropriate statement to educate the client about clozapine. Clozapine is an antipsychotic medication used to treat schizophrenia and helps with cognitive symptoms such as disorganized thinking. Choice A is too vague and doesn't specify the medication's intended effect. Choice C is too general and doesn't focus on cognitive improvement. Choice D is incorrect as clozapine does not specifically target grooming and hygiene but rather cognitive symptoms.

Correct Answer: D

Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.

Correct Answer: D

Rationale: The correct answer is D: Beractant (Survanta) 100 mg/kg per endotracheal tube. In this scenario, the infant's high respiratory rate indicates respiratory distress, likely due to immature lungs. Beractant is a pulmonary surfactant used to treat respiratory distress syndrome in preterm infants by improving lung function and reducing the risk of complications. Administering beractant via endotracheal tube helps deliver the medication directly to the lungs. Choice A (Ampicillin) is an antibiotic used for treating infections, not respiratory distress. Choice B (Gentamicin) is an antibiotic for infections, not respiratory distress. Choice C (Digoxin) is a cardiac medication for heart conditions, not respiratory distress. Therefore, only choice D addresses the respiratory distress issue in the preterm infant, making it the most appropriate drug for the transport team to administer in this case.