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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Fluconazole treats fungal infections, not RSV, a viral respiratory illness. Antivirals like ribavirin might apply, but antifungals don’t. Scientifically, this mismatches RSV’s etiology, as it’s a paramyxovirus, rendering fluconazole ineffective and irrelevant for managing this preschooler’s condition.

Choice B reason: Monitoring urine for protein assesses kidney function, unrelated to RSV, which affects lungs. Proteinuria isn’t a typical RSV sign. Scientifically, this lacks relevance, as RSV causes respiratory distress, not renal complications, making it an unnecessary action here.

Choice C reason: An X-ray of the neck targets croup or epiglottitis, not RSV, which affects lower airways. RSV needs chest imaging if severe. Scientifically, neck imaging misaligns with RSV’s pathophysiology, wasting resources when lung assessment is more pertinent.

Choice D reason: Droplet precautions prevent RSV spread via respiratory droplets, critical in preschoolers who aerosolize virus easily. Scientifically, this aligns with infection control, as RSV’s high contagiousness requires masks and isolation to protect others, a primary nursing action per guidelines.

A. Believes that his brother’s death will be reversible B. Alienates himself from his peers C. Believes his bad behavior is causing his brother’s death D. Regresses to an earlier developmental level

Correct Answer is B

Explanation

Choice A reason: Reversibility is a preschool (3-5) belief, not school-age (6-12), where permanence is grasped. Scientifically, this mismatches developmental grief stages, as school-age children understand death’s finality, making this less expected in an older sibling’s response.

Choice B reason: Alienating from peers is common in school-age grief, as sadness or guilt isolates them socially. Scientifically, this aligns with developmental psychology, where peer withdrawal reflects processing loss inwardly, a typical reaction to a sibling’s terminal illness.

Choice C reason: Bad behavior causing death is magical thinking, typical of preschoolers, not school-age kids who reason logically. Scientifically, this regresses below their cognitive stage, making it less likely than social withdrawal in grief responses.

Choice D reason: Regression (e.g., bedwetting) occurs more in younger children under stress, less in school-age. Scientifically, older kids cope via isolation or questions, not developmental backsliding, making this less characteristic than peer alienation in this age group.

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A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

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