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: C

Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.

Correct Answer: B

Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.

Correct Answer: B

Rationale: The correct answer is B: Collect his urine for 12 hours. This instruction is given because the Schilling test involves collecting urine over a specific time period to measure the absorption of vitamin B12. A is incorrect because fasting is not necessary. C is incorrect as enema is not required. D is incorrect as emptying the bladder is not part of the test procedure.

Correct Answer: A

Rationale: The correct answer is A because nosocomial pneumonia occurs in a healthcare setting, such as hospitals or long-term care facilities, where patients are at increased risk due to exposure to pathogens and weakened immune systems. Choice B is incorrect as the timeframe of onset is not limited to within 48 hours of admission. Choice C is incorrect as nosocomial pneumonia can occur in both immunocompromised and immunocompetent hosts. Choice D is incorrect as it refers to pneumonia acquired outside of a healthcare setting.

Correct Answer: D

Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.

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: B

Rationale: The correct answer is B: IV is the route of choice for rapid administration. IV route allows for quick onset of action, crucial in acutely fluid-overloaded patients needing immediate diuresis. Option A is incorrect as furosemide can be given orally too. Option C is less relevant in this urgent situation where speed is key. Option D is also incorrect as the side effects are not determined by route of administration.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. The lab value of K at 3.2 mEq/L indicates hypokalemia. 2. Digitalis can worsen hypokalemia and lead to toxicity. 3. Avoiding foods rich in potassium will prevent further lowering of potassium levels. 4. This intervention helps prevent potential digitalis toxicity in the client. Summary of why the other choices are incorrect: A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition. B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values. D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.