A 52-year-old patient complains of seeing occasional"floaters or spots" in front of his eyes. The nurse should:

Correct Answer: D

Rationale: The correct answer is D because floaters are a common and typically benign phenomenon caused by condensed vitreous fibers in the eye. A nurse should educate the patient that floaters are usually not significant and do not require immediate intervention. Option A is incorrect because counting the number of floaters is unnecessary. Option B is incorrect because presuming glaucoma without proper assessment is inappropriate. Option C is incorrect because seeing occasional floaters is a common and normal occurrence in many individuals.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.

Correct Answer: B

Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: D

Rationale: Clubbing of the fingernails is characterized by an increased angle between the nail base and the nail plate (usually 180 degrees or greater) and a spongy texture at the nail base. This is due to underlying tissue changes associated with conditions like lung disease. Choice D is correct as it accurately describes the characteristic findings of clubbing. Choices A, B, and C do not align with clubbing features. Choice A describes tenderness and firmness, not sponginess and increased angle. Choice B mentions a convex profile and ridges, which are not specific to clubbing. Choice C includes an angle of 150 degrees, which is less than the typical angle seen in clubbing.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.

Correct Answer: A

Rationale: The correct answer is A: Administer pain medication. This is the most appropriate nursing intervention because severe pain post-surgery requires immediate relief to ensure the client's comfort and aid in recovery. Pain medication helps manage pain effectively, improving the client's overall well-being and promoting healing. Monitoring vital signs (choice B) is important but secondary to pain relief in this scenario. Administering IV fluids (choice C) may be necessary for hydration but does not directly address the pain. Administering corticosteroids (choice D) is not typically indicated for severe pain post-surgery.

Correct Answer: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.