What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.
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Which nursing intervention should be prioritized for a client with congestive heart failure (CHF)?
- A. Administer diuretics
- B. Limit fluid intake
- C. Promote activity
- D. Maintain fluid balance
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life.
Summary of Incorrect Choices:
A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity.
B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation.
D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.
What should be the nurse's first action for a client who has sustained a spinal cord injury?
- A. Immobilize the spine
- B. Assess the client's airway
- C. Place the client in a supine position
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Place the client in a supine position. This is the first action because it helps prevent further injury to the spinal cord by maintaining alignment. Immobilizing the spine (choice A) is important but should come after placing the client in a supine position. Assessing the client's airway (choice B) is crucial but not the first action in a spinal cord injury. Encouraging deep breathing (choice D) is not appropriate as the priority is to stabilize the spine. In summary, placing the client in a supine position is the initial step to prevent worsening of the spinal cord injury, while the other choices are important but secondary actions.
Which food helps lower cholesterol?
- A. Fiber-rich foods
- B. Reduce diabetic ketoacidosis
- C. Lower cholesterol
- D. Reduce the need for folate
Correct Answer: C
Rationale: The correct answer is C: Lower cholesterol. Foods that help lower cholesterol typically include sources of soluble fiber, plant sterols, and healthy fats like omega-3 fatty acids. These components can lower LDL (bad) cholesterol levels and reduce the risk of heart disease. Fiber-rich foods (choice A) are beneficial for lowering cholesterol due to their ability to bind to cholesterol and remove it from the body. Reduce diabetic ketoacidosis (choice B) is unrelated to lowering cholesterol and is a serious complication of diabetes. Reduce the need for folate (choice D) is not directly related to cholesterol levels. Thus, the correct choice is C as it directly addresses the question about lowering cholesterol.
What is the most important intervention for a client with a wound infection?
- A. Administer antibiotics
- B. Apply a cold compress
- C. Apply heat to the wound
- D. Administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating wound infections as they target and eliminate the infection-causing bacteria, preventing the infection from spreading and promoting healing. Applying a cold compress (choice B) or heat (choice C) may provide temporary relief but do not address the underlying infection. Administering IV fluids (choice D) may be necessary for hydration, but it does not directly treat the infection. Antibiotics directly target the infection, making it the most important intervention for a client with a wound infection.
The nurse is performing a mental health assessment on a 5-year-old girl. Her parents are in the middle of a bitter divorce and are worried about the effect it is having on their daughter. Which of the following might lead the nurse to be concerned about the girl's mental health?
- A. She clings to her mother whenever the nurse is in the room.
- B. She appears angry and will not make eye contact with the nurse.
- C. Her mother states that the girl has begun to ride a tricycle around their yard.
- D. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce.
A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue.
B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort.
C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.