A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Correct Answer: A

Rationale: In this scenario, the nurse's priority should be option A: Administer antibiotics to the client. The rationale behind this is that osteomyelitis is a serious infection of the bone that requires immediate treatment with antibiotics to prevent further complications such as bone necrosis or systemic infection. Administering antibiotics promptly is crucial in stopping the spread of the infection and promoting the client's recovery. Option B, increasing the client's protein intake, while important for overall healing and immune function, is not the priority in this case. Option C, teaching relaxation breathing to reduce pain, is also beneficial but should come after addressing the infection itself. Option D, providing anti-pyretic therapy to reduce fever, is important but treating the underlying infection with antibiotics takes precedence. Educationally, this question highlights the importance of prioritizing interventions based on the immediate needs of the client. Understanding the urgency of treating infections promptly, especially in conditions like osteomyelitis, is essential for nurses to provide effective and timely care to their patients.

Correct Answer: C

Rationale: The correct answer is C) Assess the client's support system. When a client receives a new diagnosis of HIV, it is crucial for the nurse to first assess the client's support system. This intervention allows the nurse to understand the client's available resources, such as family, friends, or community services, which can help the client cope with the diagnosis and navigate the complexities of HIV management. Option A is incorrect because telling the family without the client's consent violates the client's right to confidentiality and autonomy. Option B may not address the client's immediate emotional needs and may not be the most appropriate intervention at this time. Option D, explaining legal requirements to tell sex partners, is premature without first assessing the client's emotional state and support system. In an educational context, it is essential for nurses to prioritize client-centered care when supporting individuals with new diagnoses. Assessing the client's support system allows for tailored interventions that consider the client's emotional well-being, autonomy, and individual needs, ultimately promoting holistic and effective care delivery.

Correct Answer: C

Rationale: In this scenario, option C is the correct answer that indicates the need for further client education. Touching the administration dropper to the eye can introduce contaminants and increase the risk of infection. This action goes against proper eye drop administration practices, emphasizing the importance of maintaining sterile technique. Option A demonstrates correct administration by instilling the prescribed number of drops into the conjunctival sac, ensuring the medication reaches the eye effectively. Option B shows proper storage of the eye drop container to prevent contamination. Option D emphasizes the importance of hand hygiene before administering eye drops to prevent infection. From an educational perspective, this question highlights the significance of proper eye drop administration to ensure the safety and effectiveness of the treatment. It underscores the importance of following specific guidelines to prevent complications and promote positive patient outcomes. Educating clients on correct administration techniques can enhance their understanding and adherence to treatment regimens, ultimately improving therapeutic outcomes.

Correct Answer: D

Rationale: The correct answer is D) Stage IV pressure injury. In this scenario, the wound showing bone and tendon at the base indicates full thickness tissue loss, which aligns with a Stage IV pressure injury. A Stage IV pressure injury involves extensive tissue necrosis or damage, potentially exposing muscle, bone, or supporting structures. This stage requires advanced wound care management to promote healing and prevent complications like infection or further tissue damage. Option A) Stage III pressure injury is incorrect because Stage III injuries do not typically involve exposure of bone or tendon, instead showing full-thickness skin loss with visible subcutaneous fat. Option B) A stage II pressure injury is incorrect as it involves partial thickness skin loss, which does not include bone or tendon exposure. Option C) A non-staging pressure injury is also incorrect because the scenario clearly describes features aligning with a specific stage of pressure injury, which in this case is Stage IV. In an educational context, understanding pressure injury staging is crucial for nurses to provide appropriate care and interventions. Recognizing the characteristics of each stage helps in accurate assessment, treatment planning, and prevention strategies to optimize patient outcomes and prevent complications.

Correct Answer: D

Rationale: In the context of diagnosing connective tissue diseases, the correct answer is D) Thyroid stimulating hormone (TSH) because TSH is a hormone produced by the pituitary gland that regulates the thyroid gland's production of thyroid hormones and is not directly related to connective tissue diseases. A) Rheumatoid factor (RF), B) Erythrocyte sedimentation rate (ESR), and C) Anti-nuclear antibody (ANA) are typically used in the diagnosis of connective tissue diseases. Rheumatoid factor is associated with conditions like rheumatoid arthritis, ESR is a marker for inflammation often elevated in conditions like systemic lupus erythematosus, and ANA is a test used to detect autoantibodies that target components of the cell nucleus, commonly seen in autoimmune diseases like systemic sclerosis. Educationally, understanding the appropriate lab tests for diagnosing different conditions is crucial for healthcare professionals to make accurate diagnoses and provide appropriate treatment. Knowing which tests are specific to certain diseases helps streamline the diagnostic process, leading to better patient outcomes. It is essential for students and practitioners to grasp the significance of each lab test in the context of different diseases to ensure effective patient care.