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 client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.

Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.

Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.

Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.

A. Affects only the spinal cord B. Manifestations include sustained muscle contractions C. Follows a recent viral infection D. Bacteria is found in improperly processed foods E. Spores are found in soil, gardens, and manure

Correct Answer is ["B","E"]

Explanation

Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.

Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.

Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.

Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.

Choice E Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.

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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

Naxlex Comprehensive Predictor Exams

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