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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Exchange transfusion treats severe conditions like hyperbilirubinemia, not HIV. It’s irrelevant for a 10-month-old’s ongoing viral management needs.

Choice B reason: Granulocyte colony-stimulating factor boosts neutrophils, not lymphocytes, in neutropenia. HIV targets CD4 cells, making this an ineffective intervention here.

Choice C reason: Droplet precautions suit respiratory infections, not HIV, which spreads via blood/body fluids. Standard precautions suffice, so this isn’t needed.

Choice D reason: Monitoring lymphocyte (CD4) count tracks HIV progression in infants. It guides antiretroviral therapy, a critical ongoing management step at 10 months.

A. Offer the client several choices at mealtimes. B. Alternate daily caregivers. C. Avoid discussing the client’s fears. D. Remind the client of the day and time often.

Correct Answer is D

Explanation

Choice A reason: Offering multiple choices overwhelms a delirious client, whose impaired cognition struggles with decisions. Scientifically, delirium reduces attention and processing, so simplifying options aids comfort, making this counterproductive to managing their acute confusional state effectively.

Choice B reason: Alternating caregivers disrupts continuity, worsening disorientation in delirium. Consistent faces aid recognition, reducing anxiety. Scientifically, familiarity stabilizes perception in acute confusion, making this detrimental to the client’s need for a predictable environment during recovery.

Choice C reason: Avoiding fears ignores emotional distress, potentially increasing agitation in delirium. Addressing concerns gently can calm. Scientifically, unaddressed anxiety exacerbates confusion, so this neglects a holistic approach needed for managing the client’s psychological state effectively.

Choice D reason: Reminding of day and time reorients the client, countering delirium’s disorientation. Frequent cues anchor perception, aiding recovery. Scientifically, this aligns with evidence-based care, as repeated orientation reduces confusion’s impact, supporting cognitive stabilization in acute delirium management.

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A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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