A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?
Place the client’s glasses on the bedside table.
Place the call light within the client’s reach.
Check on the client every 4 hr.
Place the client in a room near the nurses’ station.
The Correct Answer is B
Choice A reason: Glasses on the bedside table may be inaccessible for a quadriplegic client lacking arm movement. This doesn’t ensure immediate utility or safety. Scientifically, quadriplegia limits motor function, requiring adaptive aids within reach, making this less practical than direct assistance options.
Choice B reason: Placing the call light within reach empowers the quadriplegic client to summon help, addressing their limited mobility. This aligns with scientific rehabilitation principles, enhancing independence and safety by ensuring communication access, critical for managing needs in paralysis effectively.
Choice C reason: Checking every 4 hours is insufficient for quadriplegia, where urgent needs (e.g., pressure sores) arise faster. Scientifically, frequent monitoring is standard, and this gap risks neglect, making it less proactive than enabling client-initiated contact for timely care and intervention.
Choice D reason: A room near the station aids staff response but doesn’t guarantee immediate help without client input. Scientifically, proximity alone doesn’t address quadriplegia’s dependency needs as directly as a call light, which ensures the client can signal distress promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cardiac medications don’t contraindicate varicella vaccine, a live virus. Unless immunocompromised (e.g., via steroids), cardiac conditions don’t impair immunity enough for risk. Scientifically, this lacks evidence as a barrier, as the vaccine’s safety profile supports use in stable cardiac cases without immune suppression.
Choice B reason: Chemotherapy suppresses immunity, making live vaccines like varicella dangerous due to risk of unchecked viral replication. This contraindication is scientifically grounded, as immunocompromised states (e.g., from cancer treatment) heighten infection risk, necessitating delay until immune recovery per vaccination guidelines.
Choice C reason: Two diarrhea stools in a day isn’t a contraindication unless severe or linked to immunosuppression. Mild illness doesn’t preclude live vaccines; varicella can be given unless fever or systemic compromise exists. Scientifically, this is insufficient to halt immunization based on current evidence.
Choice D reason: Clear rhinorrhea from a cold isn’t a contraindication for varicella vaccine. Mild respiratory symptoms without fever don’t impair immune response significantly. Scientifically, guidelines allow vaccination during minor illnesses, as it poses no increased risk, distinguishing it from severe immune deficits.
Correct Answer is D
Explanation
Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.
Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.
Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.
Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.
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