A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?

Correct Answer: C

Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion. Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.

Correct Answer: A

Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for Parkinson's disease as it is converted to dopamine in the brain, replenishing dopamine levels which are depleted in Parkinson's. Selegiline and Symmetrel provide symptomatic relief but are not as effective as Levodopa. Permax is not commonly used due to its association with serious side effects like heart valve damage.

Correct Answer: D

Rationale: The correct answer is D: Refer the client to the American Cancer Society’s Reach for Recovery program or another support program. This choice is the best option as it provides the client with additional support and resources specifically tailored to individuals coping with cancer and mastectomy. The Reach for Recovery program offers emotional support, education, and practical assistance which can immensely benefit the client during this challenging time. A: Involving the client's spouse or partner is important, but support programs like Reach for Recovery can offer specialized assistance that may not be fully covered by the spouse's support alone. B: While proceeding with the next phase of treatment is important, emotional support and coping mechanisms are equally crucial, which support programs can provide. C: Asking the client to remain cheerful may put pressure on her and may not address her emotional needs adequately, unlike a support program that is designed to provide comprehensive support.

Correct Answer: A

Rationale: The correct answer is A: A hemolytic reaction to mismatched blood. Chills, dyspnea, and urticaria are indicative of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks the donor's red blood cells. This can lead to various symptoms, including fever, chills, difficulty breathing, and hives. This type of reaction is most commonly seen with mismatched blood types. Option B (A hemolytic reaction to Rh-incompatible blood) is incorrect because Rh incompatibility typically leads to hemolytic disease of the newborn, not an immediate transfusion reaction. Option C (A hemolytic allergic reaction caused by bacterial contamination of donor blood) is incorrect as bacterial contamination would present with symptoms such as fever and sepsis, not chills, dyspnea, and urticaria. Option D (None of the above) is incorrect as the symptoms presented align with a hemolytic transfusion reaction.

Correct Answer: C

Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications. A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain. B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain. D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.

Correct Answer: D

Rationale: The correct answer is D: Whisper voice test. This test is used as an initial screening for hearing loss because it is simple, quick, and easily administered by a nurse. The nurse would whisper words or numbers at a specific distance from the patient to assess their ability to hear and repeat the whispered sounds accurately. This test provides a quick indication of potential hearing impairment. The other choices are incorrect: A: Romberg test assesses balance and not hearing. B: Caloric test evaluates the vestibular system, not hearing. C: Otoscopic examination is used to examine the ear canal and tympanic membrane, not to screen for hearing loss.

Correct Answer: D

Rationale: The correct answer is D, the bicarbonate-carbonic system. This buffer system is crucial in maintaining the body's pH balance. When CO2 combines with water in the blood, it forms carbonic acid, which dissociates into bicarbonate ions and hydrogen ions. Bicarbonate acts as a base, accepting excess hydrogen ions to prevent a decrease in pH. Hemoglobin and plasma proteins primarily function as transport molecules, not as buffer systems. Phosphate buffer system is present in intracellular fluids, not as commonly in the body. The bicarbonate-carbonic system is the most prevalent buffer system in the blood and plays a vital role in regulating blood pH.

Correct Answer: A

Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.