What should be the first step in managing a client with suspected spinal cord injury?

Correct Answer: A

Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.

Correct Answer: D

Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

Correct Answer: D

Rationale: The correct answer is D: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube connects the middle ear to the nasopharynx, allowing for pressure equalization. During activities like swallowing or yawning, the tube opens to allow air to flow in or out, maintaining equal pressure. This function is crucial for proper hearing and preventing discomfort or damage to the tympanic membrane. Choice A is incorrect as cerumen is produced by ceruminous glands in the ear canal, not the eustachian tube. Choice B is incorrect as the eustachian tube normally remains closed and opens only intermittently during specific actions. Choice C is incorrect as the eustachian tube does not connect the middle and outer ear; it connects the middle ear to the nasopharynx.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. This is the first action because epinephrine is the primary treatment for anaphylaxis, a severe allergic reaction that can be life-threatening. It works quickly to reverse the symptoms by constricting blood vessels and opening airways. Administering epinephrine promptly can prevent progression to severe complications such as respiratory distress or cardiovascular collapse. Placing the client in a supine position and administering oxygen (B) may be necessary but should not delay the administration of epinephrine. Administering fluids (C) may help maintain blood pressure but is not the priority in the acute phase of anaphylaxis. Antihistamines (D) are not effective for treating the severe symptoms of anaphylaxis and should not be the first-line treatment.

Correct Answer: B

Rationale: The correct answer is B: impetigo. The characteristics of moist, thin-roofed vesicles with a thin erythematous base are classic features of impetigo, a bacterial skin infection commonly seen in children. Impetigo is highly contagious and commonly affects the face and buttocks. The presence of blisters and scabs further supports the diagnosis of impetigo. Explanation of other choices: A: Eczema typically presents as dry, itchy patches of skin with redness and scaling. It does not usually manifest as vesicles or blisters. C: Herpes zoster, also known as shingles, presents as a painful rash with grouped vesicles on one side of the body along a nerve pathway. It is uncommon in children and usually affects older individuals. D: Diaper dermatitis is a common rash in infants due to prolonged skin exposure to urine and feces. It typically presents as redness, irritation, and possibly skin breakdown in the diaper

Correct Answer: A

Rationale: The correct answer is A, administer insulin, because hyperglycemia indicates high blood sugar levels which can be effectively lowered by administering insulin. Insulin helps to move glucose from the blood into cells for energy production. Administering fluids (B) can be helpful for dehydration, but it does not directly address the high blood sugar levels. Encouraging activity (C) may help lower blood sugar levels over time, but in the immediate situation, administering insulin is more effective. Encouraging deep breathing (D) does not directly address hyperglycemia and would not be the appropriate first step in managing this condition.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, maintaining adequate hydration is crucial to support kidney function and prevent further damage. IV fluids help improve renal perfusion and promote urine output. Hemodialysis may be necessary in severe cases but initial intervention is fluid resuscitation. Administering pain relief or morphine is not the priority in acute renal failure as addressing hydration status takes precedence over pain management.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.