A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response?

Correct Answer: D

Rationale: Injury above the phrenic nerve (C3-C5) causes respiratory paralysis (D) by disrupting diaphragm innervation. Fibrillation (A) or vagus issues (B) aren't direct. Sensation/paralysis (C) is incomplete. D is correct. Rationale: Phrenic nerve loss halts breathing, a primary concern in high spinal injuries, per trauma care.

Correct Answer: D

Rationale: Neural tube defects (NTDs) like spina bifida result from failed neural tube closure. Vitamin A (choice A) supports vision, not NTD prevention. Vitamin C (choice B) aids immunity, unrelated. Iron (choice C) prevents anemia, not NTDs. Folic acid (choice D), 400 mcg daily pre-conception, reduces NTD risk by supporting cell division. D is correct, per CDC guidelines. Nurses counsel on folate, ensuring prenatal care prevents these defects.

Correct Answer: D

Rationale: Competent intervention requires knowledge (theory, e.g., drug effects), function (practical application, e.g., administration), and specific skills (techniques, e.g., injections). This trio ensures safe, effective care e.g., giving antibiotics demands understanding, execution, and precision. Leadership, autonomy, and skills mix role traits with ability, missing function's practical focus leadership coordinates, not implements. Experience, advanced education, and skills enhance competence, but experience isn't a core area; it builds on knowledge, while education overlaps. Skills, leadership, and finances are disjointed finances aren't clinical, and leadership is broader. Knowledge, function, and skills form a cohesive base, enabling nurses to act proficiently across scenarios, aligning with standards for intervention delivery.

Correct Answer: A

Rationale: Checking cast tightness by inserting a finger between cast and skin prevents circulatory compromise in a new leg cast dependent positioning worsens swelling, ice atop the cast is ineffective, and covering delays drying. Nurses assess fit, teaching elevation and monitoring for numbness, ensuring proper healing without vascular issues.

Correct Answer: B

Rationale: Grey Turner's sign is bruising on the flanks, indicating retroperitoneal hemorrhage. Myocarditis (choice A) affects the heart, with no such sign. Pancreatitis (choice B), especially severe or hemorrhagic, causes enzyme leakage and bleeding into the retroperitoneum, manifesting as Grey Turner's sign (or Cullen's sign near the navel). Pleural effusion (choice C) involves lung fluid, unrelated to flank bruising. Monteggia fracture (choice D, misspelled) is an arm injury. B is correct, as pancreatitis is the classic cause. Nurses assess this sign, monitor vitals, and manage pain/fluids, alerting physicians to potential severity.

Correct Answer: A

Rationale: High illness rate is morbidity (A) disease prevalence, per definition. Mortality (B) death, literacy (C) understanding, coordination (D) organizing not illness-specific. A fits disease burden, making it correct.

Correct Answer: B

Rationale: Stress is a response to a perceived threat (B), per Selye physiological/psychological reaction (e.g., fight-or-flight). Injury (A) is physical, disease (C) outcome, permanent (D) misstates stress varies. B best defines stress's adaptive nature, making it correct.

Correct Answer: A

Rationale: Learning is achieved when Matuts exercises and diets (A), showing behavior change, per Bloom's psychomotor domain. Repeating steps (B) is recall, not application. 'I understand' (C) lacks evidence, quiz score (D) tests knowledge, not action. A proves application, making it correct.

Correct Answer: A

Rationale: Nursing care plans are nurse-centered designed by nurses to address patient needs e.g., managing pain. Rationales justify interventions (not vice versa), they're written (not verbal), and goals vary (not fixed at two). This nurse-driven tool, per NANDA, ensures systematic, patient-focused care delivery.