A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?

Correct Answer: D

Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.

Correct Answer: B

Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.

Correct Answer: C

Rationale: The correct answer is C: Limit phosphorus and potassium intake. Patients with chronic kidney disease often have difficulty excreting phosphorus and potassium, leading to potential complications. Limiting phosphorus and potassium intake can help prevent further kidney damage and maintain electrolyte balance. Prioritizing this dietary recommendation is crucial for managing the progression of the disease. Incorrect choices: A: Increasing protein intake can put additional strain on the kidneys and may lead to further deterioration of kidney function. B: Increasing potassium intake can be dangerous for patients with chronic kidney disease as they may have difficulty regulating potassium levels. D: Decreasing fluid intake may be necessary in some cases, but it is not the priority in terms of managing chronic kidney disease.

Correct Answer: A

Rationale: The correct answer is A: Monitor the client's airway. This is the priority because airway management is crucial in ensuring adequate oxygenation and ventilation, which is essential for brain function in a client with a head injury. Maintaining a clear airway takes precedence over other actions such as administering pain relief, performing a CT scan, or monitoring intracranial pressure. While these actions are important, ensuring the client's airway is patent and adequate oxygenation is crucial for preventing further brain injury or complications.

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.

Correct Answer: A

Rationale: Administering oxygen is the most important action for a client with respiratory distress because it helps improve oxygen levels in the blood and supports breathing. Oxygen therapy can prevent hypoxia and reduce respiratory workload. Corticosteroids, bronchodilators, and analgesics may be beneficial in specific situations, but they are not the primary intervention for respiratory distress. Corticosteroids reduce inflammation, bronchodilators help open airways, and analgesics provide pain relief but do not directly address the underlying issue of inadequate oxygenation. Administering oxygen should always be the first priority in managing respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum typically caused by infection. Administering antibiotics is crucial to treat the underlying infection. IV fluids (B) may be necessary to maintain hydration, but antibiotics address the root cause. Placing the client in a supine position (C) is not a specific intervention for peritonitis. Administering epinephrine (D) is not indicated for peritonitis as it is not a treatment for infection.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.

Correct Answer: C

Rationale: The correct answer is C because monitoring vital signs and fluid status is crucial in managing chronic heart failure. This intervention helps in assessing the patient's condition, detecting any signs of deterioration, and ensuring appropriate fluid balance. Administering diuretics (A) may be necessary but should be based on the patient's fluid status. Encouraging rest (B) is important, but monitoring vital signs takes precedence. Teaching about dietary changes (D) is essential, but ensuring the patient's immediate stability through monitoring is the priority.