The nurse is assessing multiple clients. Which situation requires immediate intervention?
Stable vital signs with mild pain
Client requesting water
Client with obstructed airway
Slight fatigue
The Correct Answer is C
Airway obstruction is an acute life-threatening emergency that prevents adequate ventilation and oxygenation, leading rapidly to hypoxia, hypercapnia, and cardiac arrest if not promptly corrected. Airway patency is always the highest priority in primary nursing assessment.
Rationale:
A. Stable vital signs with mild pain is not an immediate emergency. Mild pain with stable hemodynamic parameters indicates controlled physiological status. This situation requires routine assessment and analgesic management but does not threaten airway, breathing, or circulation.
B. Requesting water is a non-urgent comfort need. Hydration needs are important for physiological balance, but this does not indicate acute compromise of oxygenation or perfusion. The nurse can safely attend to this after higher priority clinical conditions are addressed.
C. An obstructed airway is an immediate life-threatening emergency. It prevents oxygen delivery to tissues and rapidly leads to hypoxic brain injury. This requires urgent intervention using airway maneuvers, suctioning, or advanced airway support following ABC prioritization.
D. Slight fatigue is a low-priority symptom often related to rest needs, mild illness, or recovery. It does not indicate acute deterioration in respiratory or cardiovascular function. Monitoring may be required, but no emergency intervention is indicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Paraplegia results from spinal cord injury involving thoracic or lumbar segments causing bilateral lower limb motor function and sensory loss with preserved upper extremity function due to intact cervical pathways.
Rationale:
A. Temporary weakness is inconsistent with paraplegia pathology. Paraplegia results from irreversible spinal cord damage below thoracic levels producing permanent motor loss. The stem indicates complete functional deficit rather than transient neuromuscular fatigue or reversible conduction impairment requiring rehabilitation. Findings suggest permanent neurological impairment of lower limbs.
B. Paralysis of entire body indicates quadriplegia not paraplegia. Complete body involvement suggests cervical spinal cord lesion affecting all four limbs. Paraplegia specifically spares upper extremity motor and sensory function. Question stem describes lower body limitation not global neurological failure state.
C. Paraplegia refers to paralysis of lower body structures. It results from spinal cord injury below T1 or lumbar levels. Upper extremity function remains intact due to unaffected cervical segments. This presentation distinguishes it from quadriplegia involving all limbs and trunk.
D. Paralysis of arms only indicates upper limb neurological deficit. This pattern is unrelated to spinal cord injury producing paraplegia. Paraplegia affects lower extremities with preserved arm function. Cervical nerve lesions causing arm paralysis would present differently than thoracolumbar injury state.
Correct Answer is ["A","B","E"]
Explanation
Parkinson’s disease is a progressive neurodegenerative disorder caused by loss of dopaminergic neurons in the substantia nigra, resulting in bradykinesia, rigidity, resting tremor, and postural instability with progressive gait dysfunction and autonomic impairment.
Rationale:
A. Regular walking promotes mobility maintenance and delays functional decline in Parkinson’s disease. Ambulation reduces rigidity, improves gait initiation, and decreases fall risk when supervised. The stem focuses on discharge education supporting independence and neurorehabilitation strategies for motor symptom management.
B. Fresh fruits and vegetables support bowel function and nutritional balance in Parkinson’s disease. High fiber intake reduces constipation caused by decreased gastrointestinal motility and dopaminergic therapy. Antioxidant-rich foods also support general neurological health and systemic wellbeing in chronic neurodegeneration.
C. Fluid restriction to 800 mL per day is inappropriate and may worsen dehydration and orthostatic hypotension. Parkinson’s disease patients require adequate hydration to support blood pressure stability and prevent constipation. Restricting fluids increases risk of urinary tract infections and cognitive decline.
D. Minimizing exposure to outside activities promotes deconditioning and worsens motor impairment. Parkinson’s disease management encourages safe physical activity, not isolation. Reduced mobility accelerates rigidity, balance deterioration, and psychosocial decline including depression and loss of independence.
E. Use of a walker improves postural stability and reduces fall risk in Parkinson’s disease. Assistive devices compensate for freezing gait and bradykinesia. Training ensures correct use, enhancing safety during ambulation and supporting functional independence in community and home settings.
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