Correct Answer: B

Rationale: In the spinal shock phase following a spinal cord injury, the patient may have impaired bladder functioning due to the disruption of nerve pathways. Stimulating voiding using Crede's method (choice A) is not appropriate as it can increase the risk of causing further harm to the patient's bladder. Catheterizing with a straight catheter every 3 to 4 hours (choice C) is also not recommended unless there is a specific indication for catheterization. Inserting an indwelling urinary catheter to accurately measure output (choice D) is invasive and may increase the risk of infection.

Correct Answer: B

Rationale: Septic arthritis is a form of arthritis that is considered a medical emergency. It is an acute, severe infection of a joint often caused by bacteria entering the joint space. Prompt recognition and treatment are essential to prevent irreversible joint damage and systemic spread of the infection. Symptoms of septic arthritis typically include severe joint pain, swelling, redness, warmth, and decreased range of motion. The nurse should plan care to facilitate rapid diagnosis, administration of antibiotics, joint drainage if necessary, and close monitoring for complications. Osteoarthritis, gouty arthritis, and reactive arthritis are not medical emergencies and generally require different treatment approaches.

Correct Answer: C

Rationale: The correct strategy to prevent hypertension is to decrease stress. Chronic stress can lead to high blood pressure, so managing stress levels through techniques such as mindfulness, exercise, adequate sleep, and relaxation techniques can help prevent hypertension. It is not advisable to increase salt intake, reduce physical activity, or consistently take hot baths as these can exacerbate hypertension or have no significant impact on preventing it.

Correct Answer: D

Rationale: When a client has an alteration in perfusion, particularly with inadequate oxygenation, positioning to increase blood return is essential in maintaining adequate tissue perfusion and oxygenation. By positioning the client in a way that maximizes venous return to the heart, the nurse can optimize cardiac output and improve oxygen delivery to the tissues. This can include elevating the legs slightly to facilitate blood return from the lower extremities, ensuring proper alignment of the body to prevent compression of major vessels, and promoting proper body mechanics to reduce the workload on the heart. Encouraging ambulation, instructing on deep breathing, and administering medications to increase heart rate may all have their place in certain scenarios, but for a client at risk for inadequate oxygenation due to perfusion issues, positioning to optimize blood return is the most crucial consideration.

Correct Answer: C

Rationale: While the interventions of spacing out nursing activities, assisting with ADLs, and consulting with a physical therapist are appropriate for a client with cardiomyopathy experiencing activity intolerance, using passive and active range-of-motion exercises may not be suitable. In this condition, the heart muscle is weakened and may not be able to tolerate the increased activity associated with range-of-motion exercises. These exercises could potentially place additional strain on the heart and exacerbate symptoms such as shortness of breath and fatigue. It would be safer to focus on activities that do not overly stress the cardiovascular system while still promoting mobility and independence.