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: 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: 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: B

Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.

Correct Answer: C

Rationale: Step 1: Classic full-blown AIDS presents with tumors and opportunistic infections due to severe immune system suppression. Step 2: These manifestations occur when CD4 cell count drops significantly, leading to inability to fight infections. Step 3: Persistent generalized lymphadenopathy (Choice A) can be seen in early HIV infection, not necessarily in full-blown AIDS. Step 4: Sudden weight loss, fever, and malaise (Choice B) are non-specific symptoms seen in various conditions, not specific to AIDS. Step 5: Fever, weight loss, night sweats, and diarrhea (Choice D) are common symptoms but lack the specificity of tumors and opportunistic infections seen in classic full-blown AIDS.

Correct Answer: A

Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position. 1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls. 2. Avoiding throw rugs prevents tripping hazards that can lead to falls. 3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed. The incorrect choices: - Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention. - Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement. - Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest

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: B

Rationale: The correct answer is B: Make recommendations for revising the plan of care. When client outcomes are not met within the specified time frame, the nurse should reassess the plan of care to identify any potential reasons for the lack of progress. By making recommendations for revising the plan of care, the nurse can adjust interventions to better align with the client's needs and facilitate goal achievement. Continuing to follow the written plan of care (choice A) without modification may not address the underlying issues preventing goal attainment. Asking another health care professional to design a plan of care (choice C) may not be necessary if the nurse can assess and revise the current plan. Stating 'goal will be met at a later date' (choice D) does not address the need for immediate action to reassess and modify the plan for better outcomes.

Correct Answer: B

Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator. A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery. C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken. D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.