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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Documenting an overdose is premature without further assessment and evidence.
Choice B Rationale: Acute dementia is not typically diagnosed based on rapidly fluctuating moods alone, and it may not be appropriate for this situation.
Choice C Rationale: While substance abuse comorbidity may be present, it does not fully capture the client's current presentation.
Choice D Rationale: Documenting acute delirium is appropriate in this case. The client's symptoms, including rapidly fluctuating moods and delusions, are indicative of acute delirium, which can be related to substance withdrawal or other medical issues.
Correct Answer is D
Explanation
Choice A Rationale: Fecal incontinence is not typically associated with mild Alzheimer's disease but may occur in later stages.
Choice B Rationale: Urinary incontinence can occur in Alzheimer's disease, but it is not specific to the mild stage.
Choice C Rationale: Inability to smile is not a typical manifestation of Alzheimer's disease but may be related to facial muscle weakness or other factors.
Choice D Rationale: Being able to drive to familiar places is consistent with the early stage of Alzheimer's disease, where clients may still have some independence and ability to perform routine tasks.
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