A nurse is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care?

Correct Answer: A

Rationale: The correct answer is A: Draw a troponin level every four hours. Troponin levels are important indicators of myocardial infarction. Drawing troponin levels every four hours allows the nurse to closely monitor the client's cardiac enzyme levels for any signs of ongoing myocardial damage. This frequent monitoring helps in early detection of complications and guides further treatment decisions. Explanation for why the other choices are incorrect: B: Performance EKG every 12 hours - While EKG monitoring is important in assessing cardiac function, performing it every 12 hours may not be as frequent as needed in the acute phase post-myocardial infarction. C: Plant oxygen tent fell over minutes via rebreather mask - This intervention does not directly address the client's recovery from myocardial infarction and is not a standard post-MI care measure. D: Obtain a cardiac rehabilitation consult - While cardiac rehabilitation is essential for long-term recovery, it is not a point-of-care intervention immediately post-my

Correct Answer: B

Rationale: The correct answer is B because children often express grief through physical symptoms like aches and pains. This is known as somatic complaints. Children may find it difficult to articulate their emotions verbally, so physical symptoms may manifest instead. Option A is incorrect as talking about scary novels is not a common response to grief in children. Option C is incorrect as fear of leaving home is more associated with separation anxiety. Option D is incorrect as becoming obsessed with religious rituals is not a typical response to grief in children.

Correct Answer: D

Rationale: The correct answer is D because impulsivity is a common characteristic of borderline personality disorder and can lead to self-injurious behaviors. The statement "It is almost as if as soon as I think of doing something, I immediately do it" indicates a lack of impulse control and potential for engaging in harmful behaviors without considering consequences. A: This statement expresses feelings of depression but does not directly indicate self-injurious behavior risk. B: This statement suggests a lack of autonomy but does not directly indicate self-injurious behavior risk. C: This statement describes dissociation, which is common in borderline personality disorder but does not directly indicate self-injurious behavior risk. In summary, choice D is the correct answer as it directly implies impulsivity and potential for self-injurious behavior, while the other choices do not clearly indicate this risk.

Correct Answer: C

Rationale: The correct answer is C because reassuring the patient that the environment is safe can help reduce their feelings of anxiety or fear, which may be causing the aggressive behavior. This approach focuses on creating a calming and supportive atmosphere, which is essential in managing challenging behaviors in dementia patients. A: Gently touching the patient's arm may escalate the situation and provoke a negative response. B: Asking the patient 'What do you need?' may not address the underlying cause of the behavior and could be perceived as confrontational. D: Directing the patient to cease the behavior may be seen as threatening and could lead to further aggression.

Correct Answer: C

Rationale: The correct answer is C because a decrease in admission frequency to inpatient psychiatric hospitals indicates improved mental health stability and reduced need for acute care. This outcome shows that the in-home mental health care has been effective in managing the patient's condition. A: Need for continued intensive monitoring in the home suggests ongoing high risk and lack of progress. B: Need for crisis intervention services on an ongoing basis indicates persistent instability and inability to manage symptoms effectively. D: Dependence on parents to participate in care may imply lack of independence and personal growth in managing one's mental health.