The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?

Correct Answer: A

Rationale: The correct answer is A: Complete the Braden Scale. This tool assesses the risk of pressure ulcers by evaluating factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. It is crucial to complete this assessment on admission to determine the client's risk level and develop appropriate prevention strategies. B: Monitoring the client on a Glasgow Coma Scale is not relevant in this scenario as it assesses the level of consciousness, not pressure ulcer risk. C: Assessing for Babinski's sign is a neurological assessment and not related to pressure ulcer risk assessment. D: Initiating a Brudzinski flow sheet is not a recognized tool for pressure ulcer risk assessment and is not relevant in this context.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. The teacher mentions fixing her daughter's hair with her brush, which suggests direct contact with her daughter's hair, potentially spreading the infestation. 2. Pediculosis is transmitted through close contact, so using the same brush on an infested person can lead to reinfestation. 3. This action goes against the instructions discussed in the classroom to prevent the spread of pediculosis. 4. Choices A, B, and C do not involve direct contact with potentially infested individuals, making them less likely to contribute to the spread of pediculosis.

Correct Answer: C

Rationale: The correct answer is C: Reduced skin sensation in the lesions. This is a sign of a complication in leprosy known as nerve damage. In leprosy, the bacteria affect the nerves, leading to loss of sensation in the skin. This can result in injuries and infections that the client may not feel. A: Elevated temperature at night is a common symptom of leprosy but not necessarily indicative of a complication. B: Brownish-black discoloration to the skin can occur in leprosy but is not necessarily a specific sign of a complication. D: A high count of mycobacteria in the culture indicates the presence of the bacteria causing leprosy but does not directly indicate a complication.

Correct Answer: B

Rationale: The correct answer is B: Assess for airway patency. In this scenario, the client's burns are located on the face, neck, arms, and chest, which can lead to airway compromise due to swelling or inhalation injury. Assessing airway patency is crucial to ensure the client's ability to breathe. Immediate intervention may be necessary to prevent respiratory distress or failure. Restricting fluids (A) is not appropriate as fluid resuscitation may be required for burn victims. Placing a cooling blanket (C) could potentially worsen the burns by causing hypothermia. Giving oral pain medication (D) is important but not the priority in this situation where airway management is critical.

Correct Answer: C

Rationale: The correct answer is C: Inform the charge nurse and document occurrence. This is the first action because it is essential to report any work-related injuries promptly for documentation and potential follow-up care. Continuing to work (A) could worsen the injury. Going to the emergency department (B) may not be necessary if the injury is not severe. Seeing a private health-care provider on off time (D) may delay necessary documentation and follow-up within the workplace.