A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?

Correct Answer: C

Rationale: The correct initial action is to choose C: Ask the patient about the facial grimacing with movement. This is important as the patient's non-verbal cues (facial grimacing) contradict their verbal pain report. By directly addressing the discrepancy, the nurse can gather more accurate information about the patient's pain experience and potentially identify any underlying issues causing the discrepancy. Proceeding to the next patient's room (A) without addressing the discrepancy would neglect the patient's needs. Assuming the patient does not want pain medicine (B) based solely on the verbal report without further assessment is premature. Administering pain medication (D) without clarifying the situation may lead to inappropriate or ineffective treatment. Therefore, option C is the most appropriate initial action to ensure comprehensive and individualized patient care.

Correct Answer: A

Rationale: The correct answer is A: A complete thyroidectomy also. In the case of a cold nodule, which indicates potential malignancy, a total thyroidectomy is warranted to remove the entire thyroid gland to prevent the spread of cancer. A partial thyroidectomy, as in choices B and C, would not be sufficient in addressing malignancy. Administering thyroid medication, as in choice D, would not be appropriate for treating malignancy. Therefore, the correct approach is to perform a total thyroidectomy to ensure complete removal of the affected gland and to address both hyperthyroidism and potential malignancy.

Correct Answer: C

Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used. Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly. Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride. Summary: - Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration. - Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride. - Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.

Correct Answer: D

Rationale: The correct answer is D: Vitamin D. Vitamin D is essential for the absorption of calcium in the intestines. Without sufficient vitamin D, the body cannot effectively absorb calcium, leading to potential issues with calcium absorption. Vitamin A (choice A) is not directly involved in calcium absorption. Vitamin B (choice B) and Vitamin C (choice C) also do not play a significant role in calcium absorption. Therefore, the lack of Vitamin D is the most likely cause for problems with calcium absorption.

Correct Answer: B

Rationale: Step-by-step rationale: 1. CD4+ cells are a type of white blood cell crucial for immune function. 2. HIV targets and destroys CD4+ cells, leading to immune system damage. 3. Measuring CD4+ levels helps determine the extent of this damage. 4. Therefore, the correct answer is B. Summary: A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose. C: Level of the viral load - Measured separately from CD4+ levels. D: Resistance to antigens - CD4+ levels do not directly indicate resistance.

Correct Answer: C

Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions. Incorrect choices: A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment. B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management. D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.

Correct Answer: B

Rationale: Step-by-step rationale for choice B being correct: 1. Dehydration leads to electrolyte imbalances, which can exacerbate cardiac dysrhythmias. 2. Small frequent intake of fluids like juices, broth, or milk helps in gradual rehydration without overwhelming the cardiovascular system. 3. This approach allows for better absorption of fluids and nutrients, promoting hydration without causing sudden shifts in electrolyte levels. Summary of why other choices are incorrect: A: Just drinking a glass of water every hour may not address electrolyte imbalances or provide adequate hydration for a client with cardiac dysrhythmias. C: NG replacement may not be necessary if the client can tolerate oral intake, and it is more invasive than needed. D: A rapid IV infusion may lead to sudden changes in electrolyte levels, potentially worsening the dysrhythmias.

Correct Answer: D

Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.

Correct Answer: A

Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.