The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Loosen all of the connections on the vest to assess the skin

Ask about the client's ability to perform range of motion to legs

Ask how the client is able to reposition self in bed

Assess the pin sites

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.

Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.

Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.

Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.

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Correct Answer is A

Explanation

Choice A Rationale: Lentils have one of the highest fiber contents per cup compared to the other options listed, making them a good choice to help alleviate constipation.

Choice B Rationale: Asparagus is a source of fiber but typically has lower fiber content per cup compared to lentils.

Choice CRationale: Oatmeal is known for its fiber content, but its fiber content per cup is typically lower than that of lentils.

Choice DRationale: Cabbage is a source of fiber, but its fiber content per cup is usually lower than that of lentils.

A. A "It increases their risk of experiencing a stroke." B. B "It can increase their blood pressure." C. C "It can increase their risk for infection." D. D "It can increase their risk for falls."

Correct Answer is A

Explanation

Choice A Rationale: some medications that are used to calm down people with dementia can have serious side effects, especially for older adults. One of these side effects is an increased risk of experiencing a stroke, which can be life-threatening.

Choice B Rationale: Increased blood pressure can be a side effect of some medications used to calm patients with dementia, but it may not be the primary reason for not prescribing such medications. Furthermore, some medications can lower blood pressure, not increase it.

Choice C Rationale: Increased risk for infection is not typically a reason to avoid medications to calm dementia patients.

Choice D Rationale: is partially true because some medications can increase the risk for falls, but this is not the main reason why they are avoided.

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The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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