A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

A Unscrew the pins from the cervical tongs

B Ask the client to sit on the edge of the bed

C Gather supplies and at least 3 other people

D Remove the straps from the halo vest

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Unscrewing the pins from the cervical tongs is not the best first action for bathing a client with a spinal cord injury.

Choice B Rationale: Asking the client to sit on the edge of the bed may not be appropriate or safe without proper assistance and equipment.

Choice C Rationale: The best first action is to gather supplies and at least 3 other people. Bathing a client with a spinal cord injury can be complex and may require additional assistance for safety and comfort.

Choice D Rationale: Removing the straps from the halo vest is not the first step in the bathing process and may not be necessary.

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Correct Answer is A

Explanation

Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.

Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.

Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.

Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.

A. A Expected physiological changes of the disease B. B Actions to reduce stress C. C Referral to available community resources D. D Identification of a social support system E. E Instruction on client medication administration

Correct Answer is ["A","B","C","D"]

Explanation

Choice A Rationale: Understanding the expected physiological changes of Alzheimer's disease can help the caregiver better cope with the client's behaviors and needs.

Choice B Rationale: Teaching actions to reduce stress is important for both the caregiver and the client, as stress can exacerbate behavioral symptoms in Alzheimer's disease.

Choice C Rationale: Referring to available community resources can provide valuable support and assistance to both the caregiver and the client.

Choice D Rationale: Identifying a social support system is essential for the caregiver to have emotional and practical support while caring for a client with Alzheimer's disease.

Choice E Rationale: While medication administration is important, it may not be the primary focus of coping strategies for the caregiver.

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A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

Nursing Test Bank

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