A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?
Place the client’s glasses on the bedside table.
Place the call light within the client’s reach.
Check on the client every 4 hr.
Place the client in a room near the nurses’ station.
The Correct Answer is B
Choice A reason: Glasses on the bedside table may be inaccessible for a quadriplegic client lacking arm movement. This doesn’t ensure immediate utility or safety. Scientifically, quadriplegia limits motor function, requiring adaptive aids within reach, making this less practical than direct assistance options.
Choice B reason: Placing the call light within reach empowers the quadriplegic client to summon help, addressing their limited mobility. This aligns with scientific rehabilitation principles, enhancing independence and safety by ensuring communication access, critical for managing needs in paralysis effectively.
Choice C reason: Checking every 4 hours is insufficient for quadriplegia, where urgent needs (e.g., pressure sores) arise faster. Scientifically, frequent monitoring is standard, and this gap risks neglect, making it less proactive than enabling client-initiated contact for timely care and intervention.
Choice D reason: A room near the station aids staff response but doesn’t guarantee immediate help without client input. Scientifically, proximity alone doesn’t address quadriplegia’s dependency needs as directly as a call light, which ensures the client can signal distress promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Facial erythema is not a hallmark of pertussis, caused by Bordetella pertussis. It may occur in scarlet fever from Streptococcus, but pertussis features paroxysmal coughing and whooping, not facial redness, making this uncharacteristic of the respiratory infection’s typical presentation.
Choice B reason: Peeling of hands and feet is typical of Kawasaki disease or scarlet fever post-streptococcal infection, not pertussis. Pertussis affects the respiratory tract, causing mucus buildup and coughing, not dermatologic desquamation, which is unrelated to its bacterial pathogenesis.
Choice C reason: Fever is expected in pertussis as the body mounts an immune response to Bordetella pertussis, elevating temperature to fight infection. Though not always high, it accompanies the catarrhal phase, reflecting systemic inflammation, a common sign in respiratory bacterial infections.
Choice D reason: Beefy, red tongue is a feature of scarlet fever or vitamin deficiencies, not pertussis. Pertussis targets the respiratory system, causing coughing and whooping, not oral mucosal changes, making this unrelated to its pathophysiology, focusing on airway irritation.
Correct Answer is B
Explanation
Choice A reason: Bathing under running water risks temperature instability and drowning in newborns. This is unsafe, showing a lack of proper care understanding.
Choice B reason: Washing the face with a warm, wet washcloth without soap protects delicate skin, avoiding irritation. This aligns with newborn hygiene best practices.
Choice C reason: Moist towelettes often contain chemicals, unsuitable for newborn scalps. Warm water and cloth are gentler, so this reflects misunderstanding of care.
Choice D reason: Daily baths dry out newborn skin, increasing irritation risk. Spot cleaning is advised, making this an incorrect application of hygiene teaching.
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