A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?

Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Monitor for arrhythmias. This is because in a client showing signs of shock after surgery, the priority is to assess for any cardiac complications such as arrhythmias, which can be life-threatening. Monitoring for arrhythmias allows prompt identification and intervention. Administering a blood transfusion (A) may be necessary in some cases of shock but is not the first intervention. Administering oxygen (C) may also be necessary, but addressing cardiac complications takes precedence. Encouraging deep breathing (D) is not a priority in managing shock-related complications.

Correct Answer: D

Rationale: Step 1: Culturally competent care involves applying knowledge, skills, attitudes, and personal attributes to provide respectful and effective care. Step 2: Understanding and speaking the patient's mother tongue (Option A) is important but not sufficient for culturally competent care. Step 3: Possessing basic knowledge of the patient's cultural background (Option B) is helpful, but not comprehensive enough to ensure culturally competent care. Step 4: Having knowledge of the significance of social, economic, and cultural contexts (Option C) is crucial but does not encompass the full scope of culturally competent care. Step 5: The correct answer, D, encompasses the holistic approach needed for culturally competent care by emphasizing the application of knowledge, skills, attitudes, and personal attributes to maximize respect and care.

Correct Answer: C

Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.

Correct Answer: A

Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship. Explanation of other choices: B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue. C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy. D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.

Correct Answer: C

Rationale: The correct answer is C because stopping medication once blood pressure is normal can lead to a rebound increase in blood pressure, increasing the risk of stroke. A patient with a history of stroke needs to continue taking medications as prescribed to maintain optimal blood pressure control. Statements A, B, and D are all indicative of good stroke prevention strategies, such as managing blood pressure, limiting alcohol intake, and maintaining a healthy lifestyle.

Correct Answer: C

Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.

Correct Answer: D

Rationale: The correct answer is D: Huntington's chorea. Huntington's chorea is a genetic disorder characterized by involuntary, writhing, and twisting movements of the face and limbs, known as chorea. This is due to degeneration of certain brain cells. Epilepsy (A) involves seizures, not specific movements. Parkinson's (B) is characterized by tremors and rigidity, not chorea. Multiple sclerosis (C) affects the central nervous system, causing a variety of symptoms, but not typically chorea.

Correct Answer: A

Rationale: The correct answer is A: Assess the communication method preferred by the patient. This response is appropriate because it demonstrates person-centered care by respecting the patient's communication preferences. By assessing the patient's preferred communication method, the nurse can effectively communicate with the patient and provide the best care. Summary of other choices: B: Requesting a sign language interpreter may not be necessary if the patient does not use sign language. C: Using loud and exaggerated facial movements can be demeaning and ineffective in communication. D: Assuming all older adults have hearing deficits is a stereotype and may not be accurate for every individual.