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What should the nurse do first when a client with a history of hypertension presents with severe headache?
- A. Administer pain relief
- B. Monitor vital signs
- C. Monitor ECG
- D. Administer insulin
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief. The nurse should address the client's immediate symptom of severe headache to provide comfort and assess the severity of the condition. Pain relief can help decrease anxiety and prevent complications. Monitoring vital signs (B) is important but treating the symptom should take priority. Monitoring ECG (C) is not necessary for a headache presentation. Administering insulin (D) is not indicated for a client presenting with a severe headache.
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Which factor is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Rationale:
1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members.
2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem.
3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image.
4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image.
Summary:
Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following to prevent complications?
- A. Administering pain medication regularly.
- B. Encouraging deep breathing exercises.
- C. Monitoring for signs of infection.
- D. Encouraging early ambulation.
Correct Answer: D
Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.
What should the nurse do first when caring for a client with a suspected spinal cord injury?
- A. Immobilize the spine
- B. Place the client in a supine position
- C. Administer analgesics
- D. Assess the airway
Correct Answer: A
Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.
Which disease is least likely to be associated with increased potential for bleeding?
- A. metastatic liver cancer
- B. gram-negative septicemia
- C. pernicious anemia
- D. iron-deficiency anemia
Correct Answer: C
Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.
What immediate intervention should a nurse provide for a hypoglycemic client?
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice with sugar
- D. 2-3 teaspoons of honey
Correct Answer: C
Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.