A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

A Unscrew the pins from the cervical tongs

B Ask the client to sit on the edge of the bed

C Gather supplies and at least 3 other people

D Remove the straps from the halo vest

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Unscrewing the pins from the cervical tongs is not the best first action for bathing a client with a spinal cord injury.

Choice B Rationale: Asking the client to sit on the edge of the bed may not be appropriate or safe without proper assistance and equipment.

Choice C Rationale: The best first action is to gather supplies and at least 3 other people. Bathing a client with a spinal cord injury can be complex and may require additional assistance for safety and comfort.

Choice D Rationale: Removing the straps from the halo vest is not the first step in the bathing process and may not be necessary.

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Correct Answer is C

Explanation

Choice A Rationale: Educating about the importance of proper food handling is important for preventing foodborne illnesses but is not specific to the care of a client with tetanus.

Choice B Rationale: Offering food at least 4 times a day may be necessary for maintaining nutritional support, but it does not address the specific care needs of a client with tetanus.

Choice C Rationale: Anticipating administration of opioids is an important component of the care plan for tetanus. Opioids can help manage muscle spasms and severe pain associated with tetanus.

Choice D Rationale: Providing distraction activities may be beneficial for clients with tetanus to help divert their attention from muscle spasms and discomfort, but it is not the primary intervention.

A. A "He didn't remember the neighbor's name after I introduced them at the picnic" B "He discarded the utility bills but never paid them" B. C "He has been retired for 5 years but keeps talking about how excited he is to start his new job C. D "He forgets he read the newspaper and reads it over all day" D. E "found his car keys in the refrigerator and his shoes in the microwave"

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Rationale: Forgetting names and faces, especially when previously introduced, can be a sign of memory impairment, which is common in Alzheimer's disease. Choice B Rationale: Neglecting bills and financial responsibilities is a sign of impaired executive function, which can occur in Alzheimer's disease.

Choice C Rationale: Mentioning excitement about starting a new job after retirement is a typical sign of Alzheimer's disease.

Choice D Rationale: Repeatedly forgetting that one has already read the newspaper and reading it again can be a sign of short-term memory loss, a characteristic of Alzheimer's disease.

Choice E Rationale: Placing car keys in unusual places and misplacing items like shoes in unexpected locations can be signs of disorientation and memory problems, which are common in Alzheimer's disease.

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A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?

Correct Answer is C

Explanation

A family member arrives with a client indicating that they are concerned that the client is developing Alzheimer's disease. Which of the following items described by the family member are signs of Alzheimer's Disease? Select All that Apply

Correct Answer is ["A","B","C","D","E"]

Explanation

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