The nurse is caring for a client admitted with moderate neck pain and numbness and tingling in the lower extremities after falling off a trampoline. The client is alert, oriented, with spontaneous movement of all extremities, respiratory rate of 16 breaths per minute and regular, heart rate of 96 beats per minute, and blood pressure of 124/76 mmHg. What action should the nurse take?

Choice A reason: Administering furosemide without a provider’s order is outside nursing scope and risks harm. Decreasing IV fluids addresses elevated CVP, making this incorrect, as it bypasses protocol compared to the nurse’s priority of adjusting fluids and consulting the provider.

Choice B reason: A CVP of 16 cm H2O suggests fluid overload; decreasing IV fluids and notifying the provider prevents worsening heart failure. This aligns with hemodynamic monitoring protocols, making it the correct action for the nurse to take to address the client’s elevated CVP.

Choice C reason: Documenting the CVP is necessary but doesn’t address the urgent fluid overload indicated by 16 cm H2O. Decreasing fluids is proactive, making this incorrect, as it delays intervention compared to the nurse’s priority of managing the client’s high CVP.

Choice D reason: Checking urine specific gravity assesses hydration but is less urgent than addressing elevated CVP with fluid adjustment. Notifying the provider takes precedence, making this incorrect, as it’s secondary to the nurse’s action to manage fluid overload immediately.

Choice A reason: Increasing fiber during Crohn’s exacerbation worsens diarrhea and inflammation, indicating a misunderstanding. A low-fiber diet is recommended, making this the correct statement needing further instruction, as it contradicts the nurse’s teaching on managing dietary needs during Crohn’s disease flare-ups.

Choice B reason: Avoiding caffeinated beverages is correct, as they stimulate the gut and worsen Crohn’s symptoms. This aligns with dietary teaching, making it incorrect, as it shows understanding, unlike the incorrect fiber statement requiring further instruction from the nurse.

Choice C reason: Learning stress-reduction techniques is appropriate, as stress can trigger Crohn’s exacerbations. This reflects understanding of self-management, making it incorrect, as it aligns with the nurse’s teaching, unlike the fiber statement indicating a need for further dietary instruction.

Choice D reason: Recognizing exacerbations and remissions is accurate for Crohn’s disease, showing disease knowledge. This aligns with the nurse’s education, making it incorrect, as it demonstrates understanding, unlike the fiber statement that requires further instruction to correct the client’s misconception.