A nurse enters a client’s room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Notify the client's provider.

Measure the client's vital signs.

Document the fall in the client's medical record.

Complete an incident report.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the provider follows assessment; vital signs gauge injury first. Immediate stability check precedes communication in a fall scenario like this.

Choice B reason: Measuring vital signs first assesses for shock, injury, or distress post-fall. It’s the priority to ensure safety before further actions in emergencies.

Choice C reason: Documentation is essential but secondary to client stability. Vital signs determine urgency, so recording waits until immediate health risks are evaluated.

Choice D reason: Incident reports address safety trends, not acute care. Assessing vital signs first ensures the client’s condition guides subsequent reporting and intervention.

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Correct Answer is A

Explanation

Choice A reason: Shoulder harnesses at shoulder level secure the infant, distributing crash forces evenly. Scientifically, this aligns with safety standards, preventing spinal injury by stabilizing the torso, a critical car seat feature per biomechanical crash studies for optimal protection.

Choice B reason: A cushion under the head risks airway obstruction or spinal misalignment in crashes. Scientifically, added padding alters manufacturer design, increasing injury risk, as car seats are engineered for direct fit without extras per safety regulations.

Choice C reason: A 90-degree angle is upright, risking airway collapse in newborns with weak necks. Scientifically, a 30-45-degree recline supports breathing and spinal alignment, making this unsafe per pediatric and crash safety evidence.

Choice D reason: Airbags in the front seat can fatally injure infants in rear-facing seats via rapid inflation. Scientifically, back-seat placement avoids this, as airbag force exceeds infant tolerance, contradicting safety mandates for car seat positioning.

A. Echopraxia B. Aphasia C. Acute onset of confusion D. Inability to read

Correct Answer is C

Explanation

Choice A reason: Echopraxia, mimicking movements, is linked to psychiatric conditions like schizophrenia, not delirium. Delirium features disordered cognition from physiological causes (e.g., infection), not motor imitation. Scientifically, this lacks relevance to delirium’s acute, fluctuating mental state driven by underlying medical issues.

Choice B reason: Aphasia, a language deficit, stems from brain damage (e.g., stroke), not delirium’s reversible cognitive disruption. Delirium affects attention and awareness, not specific linguistic skills. Scientifically, this is distinct from delirium’s diffuse, temporary confusion tied to systemic or metabolic disturbances.

Choice C reason: Acute onset of confusion defines delirium, a sudden cognitive decline from causes like infection or drugs. It’s reversible with treatment, featuring inattention and disorientation, aligning with scientific criteria as a hallmark symptom distinguishing it from chronic conditions like dementia.

Choice D reason: Inability to read relates to literacy or focal brain injury, not delirium. Delirium impairs global cognition—attention and memory—not specific skills like reading unless confusion interferes indirectly. Scientifically, this isn’t a core feature, as delirium’s impact is broader and transient.

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A nurse enters a client’s room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Nursing Test Bank

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