An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?

Correct Answer: C

Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.

Correct Answer: C

Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.

Correct Answer: B

Rationale: The correct answer is B because the right side weakness indicates a lesion in the left hemisphere of the brain. The brain's motor functions are contralaterally controlled, meaning the left hemisphere controls the right side of the body. Therefore, a right-sided weakness suggests a lesion in the left hemisphere. The other choices are incorrect because expressive aphasia is associated with left hemisphere lesions, judgment of distance and proprioception are more related to parietal lobe lesions, and orientation to time and space is not directly linked to right-sided weakness.

Correct Answer: A

Rationale: The correct answer is A: Inform the physician. This is essential because a sudden change in vital signs may indicate a critical condition that requires immediate medical attention. The physician needs to be informed promptly to assess the situation and provide appropriate interventions. Summary: - B: Changing environmental settings is not a priority when dealing with sudden changes in vital signs. - C: Altering diet intake is not an immediate response to sudden changes in vital signs. - D: Decreasing physical activity may not address the underlying cause of the sudden change in vital signs.

Correct Answer: A

Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks. Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.