A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?

Correct Answer: D

Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support. A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls. B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls. C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies. In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.

Correct Answer: C

Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.

Correct Answer: D

Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.

Correct Answer: A

Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.

Correct Answer: D

Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.

Correct Answer: C

Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used. Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly. Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride. Summary: - Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration. - Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride. - Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.

Correct Answer: D

Rationale: The correct answer is D: 200 CD4+ cells. In AIDS, the immune system is severely compromised, leading to a decrease in CD4+ T cells. A CD4+ count below 200 cells/mm3 is a key indicator of AIDS, as it signifies advanced immunodeficiency. Choices A, B, and C all have CD4+ cell counts above 200, which would not support the occurrence of AIDS. Therefore, the nurse would evaluate a CD4+ count of 200 cells as laboratory data that support the occurrence of AIDS.

Correct Answer: D

Rationale: The correct answer is D: absence seizures. Barbiturate anticonvulsants are not effective in treating absence seizures because they can worsen this type of seizure by suppressing brain activity. Barbiturates are typically used to treat tonic-clonic seizures and partial seizures, but not absence seizures. Febrile seizures are typically managed without barbiturate anticonvulsants. In summary, barbiturate anticonvulsants are effective in treating partial seizures and tonic-clonic seizures, but not absence seizures or febrile seizures due to their mechanisms of action and potential side effects.

Correct Answer: B

Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.