A client with a spinal cord injury suddenly develops a throbbing headache, nasal congestion, and a blood pressure of 210/110 mm Hg. Which action should the nurse perform first?

Correct Answer: B

Rationale: Symptoms (headache, congestion, BP 210/110) indicate autonomic dysreflexia; checking bladder distention (B) identifies the trigger first. Medication (A) or supine (C) is secondary. Notification (D) follows. B is correct. Rationale: Removing the stimulus (e.g., bladder) halts dysreflexia, a priority per SCI protocols, preventing hypertensive crisis.

Correct Answer: A

Rationale: Deciding whether to purchase individual professional liability insurance as an LVN/LPN involves weighing personal risk, and the possibility of the organization countersuing the nurse in a lawsuit is a critical factor. Organizational insurance typically covers nurses acting within their scope, but if a lawsuit arises and the organization's interests diverge such as alleging nurse negligence they might countersue to deflect liability. Individual insurance provides independent protection, ensuring legal defense and coverage tailored to the nurse's needs. Cost, organizational coverage, and work hours are relevant but secondary; cost affects feasibility, coverage might leave gaps, and hours or work type influence risk but don't address the specific threat of a countersuit. This choice emphasizes proactive self-protection in a litigious environment, safeguarding the nurse's career and finances.

Correct Answer: A

Rationale: Individualizing a care plan is best shown by including the client's preferred times and methods, tailoring care to their unique needs and lifestyle. For instance, scheduling baths when a client feels most rested respects their routine, enhancing comfort and compliance. Writing plans manually or adapting generic ones lacks this personal touch, while matching diagnoses is standard, not individualized. This approach reflects client-centered care, ensuring interventions like wound care timing fit the individual, boosting effectiveness and satisfaction.

Correct Answer: C

Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.

Correct Answer: D

Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.