Correct Answer: A

Rationale: In a hypertensive crisis, the immediate goal is to lower blood pressure to prevent organ damage. Administering antihypertensive medications helps achieve this goal efficiently. Monitoring blood pressure is essential to assess the effectiveness of the treatment and adjust medication as needed. Providing a high-sodium diet and fluid restriction (
Choice
B) can exacerbate hypertension by increasing blood pressure. Diuretics and oxygen therapy (
Choice
C) are not the first-line treatment for hypertensive crisis, as the priority is rapid blood pressure reduction. Providing IV fluids and monitoring for kidney failure (
Choice
D) are not primary interventions for managing hypertensive crisis; the focus is on blood pressure control and organ protection.

Correct Answer: B

Rationale: A bulging posterior fontanelle is a sign of increased intracranial pressure in infants, not a common symptom after a subdural hematoma. In the context of a subdural hematoma, a decreased level of consciousness is more indicative of a complication as it can be a sign of worsening brain function due to increased pressure on the brain from the collection of blood in the subdural space. Increased appetite and high-pitched cry are not typically associated with complications of a subdural hematoma.

Correct Answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

Correct Answer: A

Rationale: The correct answer is A: Sepsis and respiratory failure. Untreated pneumonia can lead to severe complications such as sepsis, which is a life-threatening response to infection, and respiratory failure, where the lungs can no longer provide enough oxygen to the body. Heart failure and kidney failure (choice
B) are not direct complications of untreated pneumonia. Pulmonary embolism and electrolyte imbalance (choice
C) are also not commonly associated with untreated pneumonia. Liver failure and electrolyte imbalance (choice
D) are not typical complications of pneumonia.

Correct Answer: A

Rationale: The correct intervention to manage fatigue in a client receiving chemotherapy is to encourage the client to take short naps during the day. Fatigue is a common side effect of chemotherapy, and allowing the client to rest can help combat this symptom. Instructing the client to remain on bedrest (
Choice
B) is not recommended as it may lead to deconditioning and worsen fatigue. Providing a high-calorie diet (
Choice
C) may be beneficial for overall nutrition but does not directly address fatigue. Encouraging the client to increase activity levels (
Choice
D) may exacerbate fatigue instead of alleviating it.