A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:

Correct Answer: A

Rationale: Rationale: 1. Collecting a follow-up database ensures up-to-date information. 2. It allows for monitoring of medication effectiveness and any new symptoms. 3. Checking the blood pressure is essential but needs current context. 4. Asking the patient to read her record may not provide all necessary updates. 5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.

Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.

Correct Answer: A

Rationale: The correct answer is A: Check for signs of infection. This is crucial because chemotherapy weakens the immune system, increasing the risk of infections. Signs of infection such as fever, chills, sore throat, and cough should be closely monitored to prevent serious complications. Monitoring weight (B) and nutrition (C) are important but not as critical as detecting infections promptly. Checking for skin changes (D) is also important, but it is secondary to identifying and managing infections due to the immediate threat they pose to the client's health.

Correct Answer: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.

Correct Answer: B

Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.

Correct Answer: C

Rationale: The correct answer is C: Lower cholesterol. Foods that help lower cholesterol typically include sources of soluble fiber, plant sterols, and healthy fats like omega-3 fatty acids. These components can lower LDL (bad) cholesterol levels and reduce the risk of heart disease. Fiber-rich foods (choice A) are beneficial for lowering cholesterol due to their ability to bind to cholesterol and remove it from the body. Reduce diabetic ketoacidosis (choice B) is unrelated to lowering cholesterol and is a serious complication of diabetes. Reduce the need for folate (choice D) is not directly related to cholesterol levels. Thus, the correct choice is C as it directly addresses the question about lowering cholesterol.

Correct Answer: A

Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first. Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.

Correct Answer: D

Rationale: The correct answer is D because a functional assessment specifically evaluates an older adult's ability to manage day-to-day activities, such as personal care, meal preparation, and mobility. This assessment helps identify any difficulties the individual may have in performing these essential tasks, which can then inform appropriate interventions or support services. Choices A, B, and C are incorrect because they do not align with the primary focus of a functional assessment, which is to evaluate an individual's functional abilities and independence in daily living tasks, particularly in the context of aging or disability.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.