Which action is most important for a nurse caring for a client with a suspected spinal cord injury?

Correct Answer: A

Rationale: The correct answer is A: Immobilize the client. This is crucial to prevent further damage to the spinal cord. Moving a client with a suspected spinal cord injury can worsen the injury and lead to permanent damage. Immobilizing the client helps maintain spinal alignment and reduces the risk of paralysis. Providing pain relief (B) and loosening clothing (D) are important but secondary actions. Applying pressure to the chest (C) is not recommended for a suspected spinal cord injury as it can also exacerbate the injury.

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues is "A: Impaired Physical Mobility." This diagnosis accurately reflects the client's limited ability to move due to the disease's impact on coordination and muscle control. Impaired Physical Mobility addresses the specific issue of gait problems commonly seen in Parkinson's patients. Choice B, "Impaired Role Performance," does not directly address the physical limitations caused by the disease. Choice C, "Ineffective Role Performance," focuses more on the client's inability to fulfill societal roles rather than the physical aspect of gait issues. Choice D, "Powerlessness," does not capture the primary concern of impaired movement and mobility in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: B

Rationale: The correct answer is B: Perform a comprehensive physical exam. This is important because it helps assess the overall health status of the client, including cardiovascular risk factors that can affect both diabetes and hypertension. Monitoring blood glucose (A) is important for diabetes management but not specific to newly diagnosed hypertension. Checking for protein in the urine (C) is important for assessing kidney function in diabetes, but not the most crucial assessment for newly diagnosed hypertension. Assessing for urinary retention (D) is not directly related to managing diabetes and hypertension.

Correct Answer: A

Rationale: The correct answer is A: "Are you aware of having any allergies?" This question is appropriate because the patient's symptoms of pale, grey, and swollen nasal mucosa suggest an allergic reaction. By asking about allergies, the nurse can gather important information to determine the cause of the symptoms. B: "Do you have an elevated temperature?" - This question is not directly related to the patient's nasal symptoms and does not address the likely allergic reaction. C: "Have you had any symptoms of a cold?" - While cold symptoms may present similarly to allergies, the patient's specific symptoms of pale, grey, and swollen nasal mucosa are more indicative of an allergic reaction. D: "Have you been having frequent nosebleeds?" - This question does not directly address the patient's current symptoms and is not likely related to the nasal mucosa appearance described.

Correct Answer: A

Rationale: The correct answer is A: database. The patient's record, laboratory studies, objective data, and subjective data collectively form the database in healthcare. This term refers to a comprehensive collection of all pertinent information about a patient that is used for analysis, diagnosis, and treatment planning. The other choices are incorrect because B: admitting data specifically refers to information gathered at the time of admission, C: financial statement pertains to financial information, and D: discharge summary summarizes the patient's care and treatment at the time of discharge, not the entire patient record.

Correct Answer: D

Rationale: The correct answer is D because a sucking tubercle is a normal finding in infants caused by friction during breastfeeding or bottle feeding. The growth is typically painless, noninflammatory, and resolves on its own over time. This explanation reassures the mother that the condition is harmless and does not require any specific treatment. Choice A is incorrect because teething does not cause a sucking tubercle. Choice B is incorrect as there is no indication of abnormality that warrants specialist evaluation. Choice C is incorrect because chronic drooling does not typically result in a sucking tubercle.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.

Correct Answer: D

Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.