A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:

Correct Answer: C

Rationale: The correct initial action in this scenario would be to roll Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available. This position is known as the recovery position, and it is important for individuals who have suspected spinal injuries. By rolling Mr. Gabatan onto his abdomen, it helps protect his spine and prevent further injury. Placing a pad under his head provides some support, and covering him with material helps to keep him warm and comfortable while waiting for additional help to arrive. It is crucial to avoid movement, especially if there is a suspected spinal injury, as moving the individual incorrectly can worsen the injury and lead to permanent damage.

Correct Answer: A

Rationale: When a patient is placed on seizure precautions, obtaining oral temperature would be contraindicated. This is because sticking a thermometer in the mouth may pose a risk during a seizure episode, as the patient might bite down on it and cause injury. It is important to prioritize safety measures to minimize the risk of harm to the patient. Other methods of monitoring temperature, such as using a tympanic thermometer or a forehead thermometer, would be more appropriate in this situation.

Correct Answer: A

Rationale: The client is experiencing muscle weakness and numbness in his legs, which are symptoms commonly associated with hyperkalemia (high potassium levels). The potassium level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to muscle weakness, numbness, and potentially more severe complications like cardiac arrhythmias.

Correct Answer: D

Rationale: Huntington's disease is a progressive neurological disorder that affects movement, cognition, and behavior. The three main clinical manifestations of Huntington's disease are abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is characterized by involuntary jerky movements that are often random and unpredictable. Intellectual decline includes difficulties with cognitive functions such as planning, organizing, and remembering. Emotional disturbances may manifest as irritability, depression, anxiety, or mood swings. Overall, individuals with Huntington's disease experience a wide range of symptoms that impact both their physical and mental well-being.

Correct Answer: A

Rationale: In the context of pediatric nursing, understanding the common side effects of stimulant medications is crucial for providing safe and effective care to children with conditions like ADHD. The correct answer, appetite suppression (option A), is a well-documented side effect of stimulant medications like methylphenidate and amphetamines. These medications work by increasing dopamine and norepinephrine levels in the brain, leading to decreased appetite as a side effect. Option B, gastrointestinal tract symptoms, while possible with some medications, is not a common side effect of stimulant medications and is more commonly associated with other types of drugs. Sedation (option C) is also not a typical side effect of stimulant medications, as they tend to have a stimulating effect on the central nervous system. Option D, hepatitis, is not a known side effect of stimulant medications and would be more indicative of a serious adverse reaction or unrelated condition. Educationally, understanding the side effects of medications used in pediatric populations is essential for safe medication administration and patient monitoring. Nurses need to be able to recognize common side effects, like appetite suppression with stimulant medications, to educate patients and families, monitor for adverse reactions, and collaborate with healthcare providers to adjust treatment plans as needed.