A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?

Correct Answer: C

Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready. Explanation for why the other choices are incorrect: A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy. B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up. D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.

Correct Answer: A

Rationale: The correct answer is A: No bruit or thrill over the AV fistula. A bruit and thrill indicate proper blood flow through the AV fistula, essential for successful hemodialysis. Absence of these sounds can indicate AV fistula malfunction, leading to inadequate dialysis. Redness, pain, and swelling are common complications of AV fistula placement but do not require immediate reporting unless severe or accompanied by other symptoms like fever or pus drainage. Reporting the absence of a bruit or thrill promptly allows for timely intervention to prevent complications and ensure effective dialysis.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Strict control of blood glucose levels is critical in promoting healing of foot ulcers in diabetic patients. 2. High blood glucose levels can impair wound healing by affecting circulation and immune response. 3. Maintaining normal glucose levels helps optimize tissue repair and prevent further complications. 4. Regular dressing changes (B) are important but not as critical as controlling blood glucose levels. 5. Application of antibiotic ointment (C) may be necessary for infected ulcers, but not the most critical intervention. 6. Hydrotherapy treatment (D) can help with wound cleansing, but it is not as essential as controlling blood glucose levels.

Correct Answer: C

Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.

Correct Answer: B

Rationale: The correct answer is B: Limit caffeine and alcohol consumption. Hot flashes can be triggered by stimulants like caffeine and alcohol. Limiting intake can help reduce their occurrence. Increasing spicy foods (A) can actually worsen hot flashes. High-protein diets (C) and consuming more dairy products (D) do not have a direct impact on hot flashes.