a client with a spinal cord injury is preparing to return home from the rehabilitation unit which of the following statements by a family member indic

NCLEX-PN

NCLEX PN Test Bank

1. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

A. "I should raise him to a sitting position."?
B. "I should check for a fecal impaction."?
C. "I should look for a kink in the urinary catheter tubing."?
D. "I should observe whether symptoms worsen."?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

2. Why is padding on a restraint helpful?

A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
B. To help the client feel more secure.
C. To keep infection and wounds at bay.
D. To keep restraints in place.

Correct answer: A

Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.

3. How should an infant be secured in a car?

A. To hold the infant while sitting in the middle of the back seat of the car
B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

Correct answer: D

Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.

4. A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?

A. "You can receive a sedative to help you relax during the test."?
B. "There is absolutely nothing to worry about."?
C. "There is no discomfort with this test, so don't be anxious."?
D. "The test won't last long, so you can handle it."?

Correct answer: A

Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.

5. A nurse is assigned to care for four clients. Which client should the nurse assess first?

A. A client scheduled for a colonoscopy
B. A client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask
C. A client preparing for discharge after surgery
D. A client requiring a tube feeding through a gastrostomy tube

Correct answer: B

Rationale: The correct answer is a client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask. Airway management is always the priority in nursing care. Assessing this client first ensures that their airway is clear and oxygenation is adequate. Clients with compromised airways need immediate attention to prevent respiratory distress or failure. The other clients do not have immediate airway concerns and represent lower priorities in this scenario. Therefore, the nurse should prioritize assessing the client with the tracheostomy and oxygen therapy to maintain airway patency and adequate oxygenation.