A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

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: A

Rationale: The correct answer is A: Decreased urine specific gravity. In diabetes insipidus, there is an inability to concentrate urine, leading to decreased urine specific gravity. This is due to the decreased production or action of antidiuretic hormone (ADH). As a result, the kidneys are unable to reabsorb water efficiently, causing dilute urine with low specific gravity. Incorrect choices: B: Elevated urine glucose is more indicative of diabetes mellitus, not diabetes insipidus. C: Decreased serum potassium is not a typical finding in diabetes insipidus. D: Increased serum sodium can occur due to dehydration from excessive urination in diabetes insipidus, but it is not directly indicative of the condition.

Correct Answer: D

Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications. Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic. Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications. Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.

Correct Answer: B

Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers. Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning. Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning. Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.

Correct Answer: D

Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.

Correct Answer: D

Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery. Rationale for other choices: A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation. B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention. C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.

Correct Answer: C

Rationale: The correct answer is C: Monitor your blood glucose levels regularly. This is important because metformin helps lower blood sugar levels, and monitoring glucose levels helps ensure the medication is effective and the client is not experiencing hypoglycemia or hyperglycemia. Option A is incorrect because metformin should be taken with meals to reduce gastrointestinal side effects. Option B is incorrect as metformin does not typically require fluid restriction. Option D is incorrect as metformin does not affect potassium levels. Regularly monitoring blood glucose levels is crucial for managing type 2 diabetes effectively.

Correct Answer: C

Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety. 1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation. 2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention. 3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts. Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.

Correct Answer: B

Rationale: The correct answer is B: Decrease the saline to a keep-open rate. The client is showing signs of fluid overload, indicated by tachypnea and bounding pulse. By decreasing the saline to a keep-open rate, the nurse can prevent further fluid overload while maintaining IV access. Discontinuing the IV and applying pressure (choice A) is not necessary unless there is a specific issue with the IV site. Increasing the rate of the current IV solution (choice C) would worsen the fluid overload. Changing the IV fluid to 0.45% normal saline (choice D) at the same rate may not effectively address the fluid overload concern.