A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which action should the nurse take next?

Correct Answer: B

Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This action should be taken next because it can provide valuable information about the underlying cause of the patient's respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the lungs or pleural space, which could be contributing to the breathing difficulties. It is an important assessment technique to determine if there are changes in lung density or presence of abnormal sounds. Counting respirations (A) is important but may not provide immediate information on the cause of distress. Waiting for a chest x-ray (C) can delay necessary interventions. Inspecting the thorax for masses or bleeding (D) is not as crucial as assessing for changes in percussion tones in a patient experiencing sudden respiratory distress.

Correct Answer: C

Rationale: The correct answer is C: Schedule for a STAT computer tomography (CT) scan of the head. This is the priority intervention because the client is showing symptoms of a possible stroke, such as slurred speech and weakness. A CT scan will help determine if the symptoms are indeed caused by a stroke and guide further treatment. Administering rt-PA (choice A) should only be done after confirming a diagnosis of ischemic stroke to prevent complications. Discussing precipitating factors (choice B) and consulting a speech pathologist (choice D) are important but not as urgent as ruling out a stroke with a CT scan.

Correct Answer: C

Rationale: The correct answer is C: Promote safe handling and positioning. For a two-month-old infant with osteogenesis imperfecta, the primary goal of therapy is to ensure safe handling and positioning to prevent fractures and injuries due to the fragile bones characteristic of the condition. This is crucial in the early stages to promote proper development and prevent complications. Improving muscle strength and diminishing tone (A) may not be appropriate at this stage due to the fragile nature of the bones. Facilitating protected weight bearing (B) is not suitable for an infant of this age with this condition. Diminishing pulmonary secretions (D) is not the primary concern in this case.

Correct Answer: B

Rationale: The correct answer is B: Ordinal. A visual analog scale (VAS) provides data that can be ranked in order of magnitude (e.g., mild pain, moderate pain, severe pain). This indicates an ordinal scale, where the categories have a meaningful order but the differences between them may not be equal. Nominal data (choice A) is used for categories with no inherent order. Interval (choice C) and ratio (choice D) scales involve equal intervals and a true zero point, which are not present in VAS data.

Correct Answer: A

Rationale: The correct answer is A because a T12 spinal cord injury typically results in intact upper extremity function, allowing the patient to use crutches for ambulation with bilateral KAFOs for stability. Choice B is incorrect as a single-point cane is not typically sufficient for this level of injury. Choice C is incorrect as T12 injury usually allows for some level of independence in mobility. Choice D is incorrect as requiring a power wheelchair for community mobility is less likely with a T12 injury.