A patient is admitted after an automobile accident. The nurse begins the mental health examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach in this situation is to:

Correct Answer: A

Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: B

Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.

Correct Answer: C

Rationale: The correct answer is C because stopping insulin when blood sugar is normal can lead to hyperglycemia. Choice A shows understanding of managing diabetes. Choice B indicates monitoring blood sugar, crucial for diabetes management. Choice D demonstrates adherence to medication schedule, essential for controlling blood sugar levels. Stopping insulin prematurely can disrupt the balance and result in complications.

Correct Answer: C

Rationale: The correct answer is C because monitoring kidney function with regular laboratory tests is crucial in managing CKD. Regular testing helps identify changes in kidney function early, allowing for timely interventions to prevent complications. Administering diuretics (choice A) may worsen kidney function. Encouraging weight loss (choice B) may be necessary, but monitoring kidney function takes precedence. Encouraging the patient to limit fluid intake (choice D) may be necessary in some cases, but it is not the priority intervention.

Correct Answer: C

Rationale: The correct answer is C because stopping medication without doctor's approval can be harmful. Step 1: Explain the importance of adhering to medication schedule in liver disease management. Step 2: Emphasize that feeling better doesn't mean the disease is cured. Step 3: Highlight potential consequences of stopping medication prematurely. Other choices are correct: A: Avoiding alcohol is essential. B: Following medication schedule is important. D: Maintaining a healthy diet supports liver function.

Correct Answer: C

Rationale: The correct answer is C: Functional. Functional assessment focuses on roles and relationships of the client by evaluating how well they can perform daily activities and interact with others. This type of assessment provides valuable insights into a client's overall well-being and ability to function independently. Incorrect choices: A: Body systems - This type of assessment focuses on the physical structures and functions of the body, not on the client's roles and relationships. B: Head to toe - This refers to a comprehensive physical examination from head to toe, which does not specifically address the client's roles and relationships. D: Focused - This type of assessment targets a specific issue or concern, but it may not necessarily delve into the client's roles and relationships.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first action should be to ensure the client's oxygenation as chest pain could indicate decreased oxygen supply. Administering oxygen helps improve oxygen levels and can be crucial in managing potential complications. Summary of other choices: B: Administering morphine may mask the pain but doesn't address the underlying issue. C: Administering anticoagulants is not appropriate as the cause of chest pain is not related to clotting. D: Applying a warm compress is not indicated and may delay proper assessment and intervention for the chest pain.

Correct Answer: A

Rationale: The correct answer is A: Increasing physical activity and managing weight. This is important for stroke prevention as exercise can improve cardiovascular health and help maintain a healthy weight, reducing the risk of another stroke. Increasing sodium intake (B) can actually elevate blood pressure, increasing stroke risk. Avoiding physical activity (C) can lead to a sedentary lifestyle, which is detrimental to stroke prevention. Consuming high-calorie, high-fat foods (D) can contribute to obesity and other risk factors for stroke. Prioritizing physical activity and weight management aligns with evidence-based guidelines for stroke prevention.