A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?

Correct Answer: C

Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.

Correct Answer: D

Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

Correct Answer: D

Rationale: The correct answer is D: Check for neurologic status. This is the first action because assessing the patient's neurologic status helps identify any immediate threats to their health and guides further interventions. It is crucial to ensure the patient's safety and prioritize interventions based on their neurologic status. Starting an IV for fluids (A), getting an ECG (B), and placing a Foley catheter (C) are important interventions but should come after assessing the patient's neurologic status to address any urgent issues first.

Correct Answer: D

Rationale: The correct answer is D: Strengthens heart contraction. Digoxin is an inotropic agent that works by increasing the force of the heart's contractions. This leads to improved cardiac output and helps manage conditions like heart failure. Choices A, B, and C are incorrect because digoxin does not decrease heart rate, increase conduction time, or increase heart rate. It specifically targets the strength of the heart's contractions, making option D the most appropriate choice. This action of digoxin is crucial in improving the efficiency of the heart's pumping function.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing, which is a general observation, before moving on to more specific details. This approach allows the nurse to gather comprehensive information systematically. A: Gordon’s Functional Health Patterns involves assessing a patient's health across several categories, not specifically related to wound care. B: Activity-exercise pattern assessment focuses on the patient's physical activity and exercise routines, not the wound dressing. D: Problem-oriented assessment involves identifying and addressing specific health issues, rather than starting with a general observation like the appearance of a surgical dressing.

Correct Answer: B

Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown. Incorrect choices: A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case. C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity. D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.

Correct Answer: B

Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.