The nurse is caring for a client with a spinal cord injury who is receiving intravenous fluids. Which finding indicates that the client is experiencing fluid overload?

Correct Answer: A

Rationale: Crackles (A) indicate fluid overload in SCI from excess IV fluids entering alveoli. Normal BP (B), pulse (C), or output (D) don't suggest this. A is correct. Rationale: Pulmonary edema from overload requires fluid adjustment, per critical care monitoring, critical in immobile SCI patients.

Correct Answer: A

Rationale: Responding to a client's fear of radiation by suggesting ways to reduce it, while explaining the nurse must stay distant, balances empathy with safety. Radiation exposure risks prevent close contact, making hand-holding or permission-seeking impractical and hazardous. Dismissing fear invalidates the client's feelings. Offering alternatives like relaxation techniques addresses anxiety constructively, aligning with nursing's supportive role while adhering to radiation protocols.

Correct Answer: C

Rationale: Endocrine glands release hormones into the blood, unlike exocrine glands with ducts (sweat, sebaceous). They're epithelial-based. This educates clients on hormonal effects, a nursing teaching role.

Correct Answer: B

Rationale: Hyperpyrexia means a very high fever (e.g., 41°C), not bleeding, waxy muscles, or burns. Nurses recognize this for urgent temperature management.

Correct Answer: C

Rationale: Plain vanilla ice cream fits a full liquid diet, melting to liquid, meeting the client's request safely. Denying, calling, or deferring misses this. Nurses accommodate within guidelines.