A patient of African descent is in the critical care unit to be monitored for shock after an accident. What skin characteristics would the nurse expect to find in this patient?

Correct Answer: C

Rationale: The correct answer is C: Ashen, grey, or dull. In patients of African descent, skin characteristics may appear ashen, grey, or dull when experiencing shock due to reduced blood flow and oxygen delivery. This is because the skin may appear pale or lacking in color due to decreased perfusion. The other choices are incorrect because: A: Ruddy blue - Ruddy blue skin color is not typically associated with shock in patients of African descent. B: Generalized pallor - Generalized pallor refers to an overall paleness of the skin, which is not commonly seen in patients of African descent during shock. D: Patchy areas of pallor - Patchy areas of pallor suggest uneven skin color changes, which are not typically characteristic of shock in patients of African descent.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.

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: Increased white blood cell count. When a client has an infection, the body's immune response triggers an increase in white blood cells to help fight off the infection. Neutrophils and band cells (choice B) may also increase during infection, but a general increase in white blood cells is a more reliable indicator. ESR (choice C) is a nonspecific marker of inflammation and may be elevated in various conditions, not just infection. LDH (choice D) is an enzyme found in many tissues and can be elevated in various conditions, not specifically infection. Therefore, an increased white blood cell count is the most indicative of infection in a client with a fever.

Correct Answer: B

Rationale: The correct answer is B because critical thinking involves anticipating potential issues to provide proactive care. By predicting potential problems, nurses can prevent complications and tailor interventions accordingly. This step is essential in the nursing process to ensure comprehensive and effective care. Continuing to reassess (A) is important but not the primary focus of a nursing diagnosis. Checking the appropriateness of goals (C) is crucial but comes after identifying the problem and predicting potential issues. Modifying the diagnosis if necessary (D) is a part of critical thinking but not the immediate next step after identifying the actual problem.

Correct Answer: D

Rationale: The correct answer is D because clinical practice guidelines for periodic health examinations provide a frequency schedule for health visits based on age. This is crucial for ensuring timely preventive care and monitoring of growth and development. Choice A is incorrect as guidelines focus on preventive care, not diagnosing illnesses. Choice B is incorrect because while guidelines may mention developmental milestones, their primary focus is on health maintenance. Choice C is incorrect as guidelines recommend health visits based on individual needs, not a one-size-fits-all annual physical examination.

Correct Answer: B

Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.

Correct Answer: D

Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment. Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.

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.