A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

Correct Answer: B

Rationale: The correct answer is B: Intracranial pressure (ICP) of 20 mm Hg. Elevated ICP can lead to increased intracranial pressure, which can further damage brain tissue and impair cerebral perfusion. This is a critical finding that requires immediate intervention to prevent further brain damage. A: Urine output of 100 mL/hour is within the normal range and does not pose an immediate threat to the client's condition. C: Respiratory rate of 12 breaths/minute is within normal limits and does not indicate an immediate concern. D: Mean arterial pressure (MAP) of 70 mm Hg is within the normal range for most adults and does not require immediate intervention in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm. A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation. B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation. C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.

Correct Answer: C

Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety. 1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation. 2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention. 3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts. Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.

Correct Answer: D

Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.

Correct Answer: D

Rationale: The correct answer is D: Teach them to limit sugar and caffeine intake. Rationale: 1. Sugar and caffeine intake can exacerbate anxiety and interfere with sleep due to their stimulant effects. 2. Limiting these substances can help regulate the body's energy levels and reduce anxiety symptoms. 3. By teaching the client to limit sugar and caffeine intake, the nurse is addressing the root causes of the client's sleeplessness and anxiety. Summary: A: Encouraging daily rituals may provide structure but does not directly address the physiological effects of sugar and caffeine on anxiety. B: Reinforcing the reality of the financial situation may increase anxiety rather than alleviate it. C: Drinking red wine at bedtime is not a recommended solution for managing anxiety and sleeplessness.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Levothyroxine is a lifelong medication for hypothyroidism. 2. Stopping medication prematurely can lead to symptom relapse. 3. Symptoms improving doesn't indicate the underlying condition is resolved. 4. Regular monitoring and dose adjustments are crucial. 5. Choice D shows misunderstanding of treatment duration and necessity. Summary: A: Correct, taking in the morning maximizes absorption. B: Correct, monitoring is necessary for dose adjustments. C: Correct, weight loss can affect thyroid hormone levels. D: Incorrect, as stopping medication prematurely is not advised.

Correct Answer: C

Rationale: The correct answer is C: Ultrasonography and nonstress test. At 38 weeks gestation, a biophysical profile (BPP) is typically done to assess fetal well-being. Ultrasonography is used to evaluate fetal movements, tone, breathing movements, and amniotic fluid volume. The nonstress test assesses fetal heart rate in response to fetal movement, indicating fetal well-being. Chorionic villus sampling (A) and amniocentesis (B) are invasive procedures not typically done as part of a routine BPP. Oxytocin challenge test (D) is not indicated in this scenario as it is used to assess placental function in high-risk pregnancies.

Correct Answer: B

Rationale: The correct answer is B because nitroglycerin tablets should be stored in a dark, glass container to protect them from light and moisture, which could decrease their effectiveness. Storing them in any other container could lead to degradation of the medication. Choice A is incorrect because nitroglycerin should be taken sublingually, not with food. Choice C is incorrect because nitroglycerin should be placed under the tongue to be absorbed quickly, not swallowed whole. Choice D is incorrect because experiencing a headache is a common side effect of nitroglycerin and does not indicate that the medication should be discontinued.

Correct Answer: B

Rationale: The correct answer is B: Hold the medication and notify the healthcare provider. The rationale is that metoprolol is a beta-blocker that can further decrease heart rate. With a low apical pulse of 58 beats/minute, administering metoprolol can potentially cause bradycardia or further slow down the heart rate to dangerous levels. Holding the medication and notifying the healthcare provider allows for further assessment and potential adjustment of the dosage or consideration of alternative treatments. Incorrect choices: A: Administering the medication as prescribed can lead to bradycardia and potential harm to the client. C: Giving half the prescribed dose and rechecking the pulse in 30 minutes can still lead to further bradycardia and potential harm. D: Administering the medication and then rechecking the pulse in 30 minutes is not appropriate as the initial pulse rate is already low, and waiting to recheck could lead to adverse effects before intervention.