When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Assess the extremity reflexes.

Logroll to change positions.

Immobilize the head in anatomical alignment.

Obtain hourly neurological assessments.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.

Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.

Choice C reason:

The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.

Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.

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Correct Answer is C

Explanation

Choice A reason: Demonstrating accurate eye care is important but is not a measurable outcome for managing diabetes.

Choice B reason: Managing blood pressure is important but not the primary goal in the context of newly diagnosed diabetes.

Choice C reason:

The correct answer is c) because achieving a hemoglobin A1C of less than 7% in 3 months is a measurable and relevant outcome for managing type 2 diabetes. It indicates good glycemic control and helps prevent complications.

Choice D reason: Encouraging physical activity is beneficial but is not a specific measurable outcome for diabetes management.

A. Determine the ability to chew and swallow. B. Assess patterns of speech. C. Note the frequency of drooling. D. Observe the appearance of oral mucosa.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because a mask-like face in Parkinson's disease can affect the ability to chew and swallow, increasing the risk of aspiration and nutritional deficiencies.

Choice B reason: Assessing speech patterns is important but secondary to ensuring the client can chew and swallow safely.

Choice C reason: Noting the frequency of drooling can indicate difficulties with swallowing, but determining the ability to chew and swallow is more critical.

Choice D reason: Observing the appearance of the oral mucosa is important for overall oral health but does not address the immediate risk of aspiration and nutritional concerns.

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When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

Correct Answer is C

Explanation

The nurse observes that a client with Parkinson's disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?

Correct Answer is A

Explanation

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