Correct Answer: A

Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis. Incorrect choices: B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly. C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness. D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.

Correct Answer: C

Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.

Correct Answer: A

Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue. Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.

Correct Answer: C

Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Providing oral care does not directly address fluid balance or hydration status. 2. Oral care focuses on maintaining oral hygiene and preventing infections. 3. Choices A, B, and D all involve fluid intake to address dehydration. 4. Offering large amounts of fluid, enteral or parenteral fluids, and small volumes at frequent intervals all aim to correct the patient's condition by replenishing lost fluids. Summary: Choice C is incorrect because oral care does not directly address the patient's dehydration. Choices A, B, and D are better options as they focus on fluid replacement to correct the patient's condition.