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 see whether symptoms worsen."

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A nurse is working in a patient's room who is positive for C. Diff (clostridium difficile).
What is the best action for the nurse to take?

• A.Don a mask, gown, and gloves when working with this patient.
• B.Wear gloves and gown during patient care.
• C.Wear gloves when having any physical contact with the patient.
• D.Wear gloves and a mask when cleaning the patient.

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Which of the following vaccines is a live virus?

• A.varicella
• B.IPV
• C.DTaP
• D.hepatitis B

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An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:

• A.inform the client that because she is underage, she is at fault for attending a party where alcohol was served.
• B.ask the client if anyone witnessed the event because the client was intoxicated and might not remember correctly.
• C.inform the client that it was not her fault, and support the client through the physical examination.
• D.question whether the woman had consensual sex and now just feels guilty.

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To ensure proper immobilization and increase client comfort when using a rigid splint:

• A.place the client on a stretcher before splinting.
• B.place the client on a long spine board before splinting.
• C.pad the spaces between the body part and the splint.
• D.ensure that the splint conforms to the body curves.

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