Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (
A) refers to information focused on the client's perspective, subjective data (
B) is based on the client's symptoms or feelings, and unconfirmed data (
C) lacks validation or evidence, making them unreliable for making clinical decisions.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and
D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (
C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

Correct Answer: B

Rationale:
Rationale:

1. GERD: Lying down after eating can worsen symptoms due to acid reflux. Sitting up helps prevent acid reflux.
2. Dumping Syndrome: Lying down can exacerbate symptoms like nausea and dizziness. Sitting up aids in digestion.
3.
Choice B recommends lying down 1 hour after eating for Dumping Syndrome and sitting up at least 30 minutes after eating for GERD, which aligns with the management of both conditions.

Summary:
-
Choice A is incorrect as lying flat after meals worsens GERD and Dumping Syndrome symptoms.
-
Choice C is incorrect as sitting up only after meals does not address the specific needs of GERD and Dumping Syndrome.
-
Choice D is incorrect as lying down after meals is not recommended for either condition.

Correct Answer: D

Rationale: The correct answer is D. When a client refuses medication, the nurse should document the refusal for legal and communication purposes. Informing the healthcare provider ensures ongoing assessment and potential alternatives.
Choice A lacks communication with the healthcare team.
Choice B may not address the underlying issue.
Choice C assumes alternative treatment is necessary without further evaluation.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for a client with a suspected myocardial infarction as it helps dilate coronary arteries, improving blood flow to the heart muscle. This helps reduce chest pain and minimize myocardial damage. Administering fluids (
B) may be necessary but not the priority. Placing the client in a sitting position (
C) could worsen symptoms. Administering aspirin (
D) is important but not as immediate as nitroglycerin for acute pain relief.