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The healthcare provider is caring for a client with a urinary tract infection. Which finding requires immediate intervention?
- A. Dysuria.
- B. Hematuria.
- C. Fever.
- D. Urinary frequency.
Correct Answer: C
Rationale: Fever can indicate a severe infection, such as pyelonephritis, in a client with a urinary tract infection and requires immediate intervention. Hematuria and dysuria are common symptoms of a urinary tract infection but may not always require immediate intervention unless severe. Urinary frequency is also a common symptom and does not indicate the severity of the infection as fever does.
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The healthcare provider is planning a health education session for new parents on infant care. Which topic should be prioritized?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Recognizing signs of infant dehydration is crucial for ensuring the health and well-being of infants. Dehydration can be life-threatening for infants if not addressed promptly. Proper diaper changing techniques, while important for hygiene, can be learned incrementally. The immunization schedule and breastfeeding positions are also essential topics, but identifying signs of dehydration takes precedence as it requires immediate attention to prevent serious complications.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client is able to expectorate secretions easily.
- B. The client's oxygen saturation is 92%.
- C. The client's respiratory rate is 20 breaths per minute.
- D. The client's arterial blood gases show a pH of 7.35.
Correct Answer: C
Rationale: In a client with COPD receiving oxygen therapy, an effective response is indicated by a respiratory rate of 20 breaths per minute. This suggests that the client is effectively oxygenating while maintaining an appropriate respiratory rate. Choices A, B, and D are incorrect because expectorating secretions easily, having an oxygen saturation of 92%, and arterial blood gases showing a pH of 7.35 are not specific indicators of the effectiveness of oxygen therapy in COPD. Oxygen saturation of 92% may still be suboptimal in COPD, and arterial blood gases showing a pH of 7.35 may not necessarily reflect the overall effectiveness of oxygen therapy.
A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Blood pressure of 130/80 mm Hg.
- C. Respiratory rate of 20 breaths per minute.
- D. Chest pain radiating to the left arm.
Correct Answer: D
Rationale: The correct answer is D. Chest pain radiating to the left arm can be a sign of myocardial infarction (heart attack) and requires immediate intervention. This symptom is known as a classic presentation of a heart attack and warrants urgent medical attention to prevent further cardiac damage. Choices A, B, and C are not directly indicative of an acute cardiac event and may not require immediate intervention in this scenario. While heart rate, blood pressure, and respiratory rate are important vital signs to monitor, they do not specifically indicate the urgency associated with chest pain radiating to the left arm in a patient with a history of coronary artery disease.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?
- A. Hypertension.
- B. Diabetes mellitus.
- C. Inadequate lifestyle changes in diet and exercise.
- D. Increased risk of chronic illnesses.
Correct Answer: C
Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.
On a day when the temperature is expected to drop below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces available in a shelter. It is most important for which person to be admitted at night?
- A. an adult who was hit by a car 3 weeks ago
- B. a young person with diabetes mellitus
- C. a middle-aged person who has hypertension
- D. an older person who is malnourished
Correct Answer: D
Rationale: Malnourished individuals are at higher risk of severe complications from cold exposure due to their weakened immune system and decreased ability to regulate body temperature. This places them at a greater risk of hypothermia and other cold-related conditions, making them the most vulnerable group in need of shelter. Choice A is not the most critical as the injury is from 3 weeks ago and should have received appropriate medical care by now. Choice B, a young person with diabetes mellitus, while vulnerable, can manage their condition with proper medication and care. Choice C, a middle-aged person with hypertension, may need monitoring but is less susceptible to immediate harm from cold exposure compared to a malnourished individual.