A nurse is caring for a patient with diabetes who is newly diagnosed with diabetic nephropathy. The nurse should prioritize which of the following assessments?

Correct Answer: A

Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This intervention is crucial for a client with an obstructed airway as it helps maintain oxygenation while efforts are made to clear the obstruction. Oxygen administration ensures the client receives adequate oxygen supply to prevent hypoxia and further complications. Monitoring respiratory rate (B) is important but not the priority when airway obstruction is present. Applying a cold compress (C) or administering corticosteroids (D) are not appropriate interventions for an obstructed airway and do not address the immediate need for adequate oxygenation.

Correct Answer: D

Rationale: Rationale: 1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members. 2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem. 3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image. 4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image. Summary: Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. During chemotherapy, neutropenia, a decrease in white blood cells, can occur, leading to increased risk of infections. Monitoring for neutropenia is crucial for timely intervention. Hyperkalemia (B) is not commonly associated with chemotherapy. Hypoglycemia (C) is more related to diabetes or insulin therapy. Chronic pain (D) is not a typical complication of chemotherapy. Monitoring for neutropenia allows the nurse to provide appropriate care to prevent infections and ensure the patient's safety.

Correct Answer: D

Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The nurse should address the client's immediate symptom of severe headache to provide comfort and assess the severity of the condition. Pain relief can help decrease anxiety and prevent complications. Monitoring vital signs (B) is important but treating the symptom should take priority. Monitoring ECG (C) is not necessary for a headache presentation. Administering insulin (D) is not indicated for a client presenting with a severe headache.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to elevated levels in the blood. This can result in life-threatening cardiac arrhythmias. Monitoring for hyperkalemia is crucial in managing patients with kidney disease. Other choices are incorrect because: B: Hypoglycemia is not typically associated with chronic kidney disease. C: Hypotension may occur in kidney disease but is not directly related to decreased renal function. D: Hypercalcemia is not a common complication of decreased renal function; in fact, kidney disease can lead to low levels of calcium.

Correct Answer: D

Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions. Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.