A patient is experiencing tingling sensations in her feet and has also noticed that her tongue has become very red and painful. The nurse suspects that she has:

Correct Answer: B

Rationale: The correct answer is B: Pernicious anemia. This condition is characterized by a deficiency in vitamin B12, leading to neurological symptoms like tingling sensations in the feet (peripheral neuropathy) and glossitis, causing the tongue to become red and painful. Polycythemia (A) is an increase in red blood cell mass, not related to the symptoms described. Micronucleus anemia (C) is not a recognized medical condition. Iron-deficiency anemia (D) can lead to symptoms like fatigue and pallor, but not typically tingling sensations in the feet or glossitis.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are crucial in treating DVT as they prevent blood clots from getting larger and stop new clots from forming. They help reduce the risk of complications like pulmonary embolism. Administering analgesics (B) may help with pain but does not address the root cause. Diuretics (C) are used to treat conditions like fluid retention, not DVT. Applying a warm compress (D) can actually worsen DVT by promoting blood flow. Anticoagulants are the gold standard treatment for DVT.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.

Correct Answer: B

Rationale: The correct answer is B because a functional health assessment evaluates various health patterns such as roles, relationships, coping mechanisms, stress tolerance, and lifestyle choices, providing a holistic view of the individual's well-being. Vital signs and circulation (A) are typically included in a physical assessment, not a functional health assessment. Assessing specific organ abnormalities (C) would be part of a focused physical examination or diagnostic testing. Acute symptoms (D) are important to address but do not encompass the comprehensive evaluation of health patterns that a functional health assessment covers.

Correct Answer: D

Rationale: The correct answer is D: Colace. When a client is immobilized and experiencing constipation, a stool softener like Colace is appropriate to prevent straining and discomfort. Advil and Anasaid are pain relievers, not laxatives. Clinocil is not a recognized medication. Colace is the best choice to address constipation in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Assessment. Assessment is the first step in the nursing process where data is collected through health history, physical examination, and interview. This step helps in identifying the patient's needs and health problems. Planning (A) comes after assessment and involves setting goals and creating a care plan. Diagnosis (B) is the step where nursing diagnoses are formulated based on the assessment data. Evaluation (C) is the final step where the effectiveness of the care plan is assessed. In summary, Assessment is the initial step focused on data collection, making it the correct choice.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Sodium restriction helps prevent fluid retention and high blood pressure in CKD. 2. Limiting sodium intake is crucial in managing CKD-related complications. 3. Excess sodium can worsen fluid retention and strain the kidneys. 4. Proper understanding of sodium limitation shows patient's grasp of CKD management. Incorrect Choices: B. Increasing fluid intake can worsen fluid retention in CKD patients. C. Excessive protein intake can burden the kidneys in CKD. D. High potassium levels in CKD can lead to dangerous heart rhythm abnormalities.

Correct Answer: A

Rationale: The correct answer is A because as a nurse, it is essential to respect and accommodate the cultural beliefs and preferences of patients. By offering to assist in arranging for the presence of the medicine woman, the nurse shows empathy, cultural competence, and patient-centered care. This approach promotes trust, communication, and collaboration with the patient. Choice B is incorrect as it disregards the patient's request and shows a lack of respect for their beliefs. Choice C is incorrect as it dismisses the significance of the patient's request, which can impact the therapeutic relationship. Choice D is incorrect as it invalidates the patient's beliefs and cultural practices, which can lead to feelings of disrespect and lack of trust.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.