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: Mouthing objects is normal at 4 months, aiding exploration and teething. It’s developmentally appropriate, not requiring provider notification at this stage.
Choice B reason: Anterior fontanel closure before 9-18 months may signal craniosynostosis, affecting brain growth. This premature finding warrants urgent provider evaluation.
Choice C reason: Rolling back to abdomen is a 4-6-month milestone, expected here. It’s a healthy motor development sign, not needing provider attention.
Choice D reason: Posterior fontanel often closes by 2-3 months, normal at 4 months. This aligns with typical infant skull development, not a concern.
Correct Answer is C
Explanation
Choice A reason: Echopraxia, mimicking movements, is linked to psychiatric conditions like schizophrenia, not delirium. Delirium features disordered cognition from physiological causes (e.g., infection), not motor imitation. Scientifically, this lacks relevance to delirium’s acute, fluctuating mental state driven by underlying medical issues.
Choice B reason: Aphasia, a language deficit, stems from brain damage (e.g., stroke), not delirium’s reversible cognitive disruption. Delirium affects attention and awareness, not specific linguistic skills. Scientifically, this is distinct from delirium’s diffuse, temporary confusion tied to systemic or metabolic disturbances.
Choice C reason: Acute onset of confusion defines delirium, a sudden cognitive decline from causes like infection or drugs. It’s reversible with treatment, featuring inattention and disorientation, aligning with scientific criteria as a hallmark symptom distinguishing it from chronic conditions like dementia.
Choice D reason: Inability to read relates to literacy or focal brain injury, not delirium. Delirium impairs global cognition—attention and memory—not specific skills like reading unless confusion interferes indirectly. Scientifically, this isn’t a core feature, as delirium’s impact is broader and transient.
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