When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Assess the extremity reflexes.

Logroll to change positions.

Immobilize the head in anatomical alignment.

Obtain hourly neurological assessments.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.

Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.

Choice C reason:

The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.

Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.

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Correct Answer is C

Explanation

Choice A reason: Altered tissue perfusion is important but not the primary concern in osteomalacia.

Choice B reason: Sleep pattern disturbance may occur but is not the highest priority.

Choice C reason:

The correct answer is c) because clients with osteomalacia have weakened bones and are at high risk for fractures, making injury prevention the highest priority.

Choice D reason: Risk of infection is important but not the primary concern in osteomalacia.

A. Deep partial-thickness. B. Full-thickness. C. Superficial partial-thickness. D. Deep full-thickness.

Correct Answer is B

Explanation

Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.

Choice B reason:

The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.

Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.

Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.

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When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Correct Answer is C

Explanation

The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

Correct Answer is B

Explanation

A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?