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 D
Explanation
Choice A reason: Responding to family requires clinical judgment and communication skills beyond AP scope. Nurses handle this in mass casualty for accuracy.
Choice B reason: Triage prioritization needs nursing assessment skills, not AP training. Determining care order is a licensed responsibility in emergencies like this.
Choice C reason: Cleaning and dressing wounds involves sterile technique and assessment, outside AP scope. Nurses perform this in mass casualty settings.
Choice D reason: Taking vital signs is within AP scope, providing data for nurse triage. It’s a routine task, safely assigned in a mass casualty event.
Correct Answer is A
Explanation
Choice A reason: Monitoring post-meals prevents purging, a common anorexia behavior. One hour ensures food retention, supporting nutritional recovery and countering compensatory actions effectively.
Choice B reason: Weighing every 2 days tracks trends, but daily is standard in anorexia to monitor refeeding risks like edema or cardiac strain more closely.
Choice C reason: Vital signs twice weekly miss acute changes in anorexia, like bradycardia from malnutrition. Daily checks are needed for safety during early treatment.
Choice D reason: Two hours per meal allows purging opportunities in anorexia. Shorter, supervised times prevent this, ensuring intake for nutritional rehabilitation success.
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