Correct Answer: C

Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.

Correct Answer: B

Rationale: The correct answer is B because the patient's Body Mass Index (BMI) indicates obesity, putting them at higher risk for surgical complications. Obesity is associated with increased risks of infections, delayed wound healing, respiratory issues, and cardiovascular problems post-surgery. Monitoring this patient closely is crucial. Choice A is less likely to have increased surgical complications due to age and condition. Choice C, a 12-year-old, is less likely to have significant surgical complications compared to adults. Choice D, a 17-year-old with gallstones, may have risks but the BMI of the patient in choice B indicates a higher risk.

Correct Answer: B

Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes. Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.

Correct Answer: A

Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is crucial for preventing infection when accessing or caring for an invasive monitoring system like a subdural intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field, washing hands, using sterile gloves, and using sterile supplies to minimize the risk of contamination. This is essential to prevent introducing harmful microorganisms into the patient's system. Using clean technique (B) or sterile technique only when cleansing the insertion site (C) may not provide adequate protection against infection. Closing leaks in the tubing with tape (D) is not an appropriate method for preventing infection and can lead to complications.

Correct Answer: B

Rationale: The correct answer is B: Pericardial friction rub. This is a key diagnostic sign of pericarditis due to the inflammation of the pericardial layers causing a rough, grating sound heard upon auscultation. Precordial pain (A) is a common symptom but not a specific diagnostic sign. Hypotension (C) and rapid/labored respirations (D) are not typically associated with pericarditis. Therefore, the presence of a pericardial friction rub is crucial in confirming the diagnosis of pericarditis.