A woman is discussing the problems she is having with her 2-year-old son. She says, 'He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens.' The nurse's best verbal response would be:

Correct Answer: B

Rationale: The correct answer is B: "Fits? Tell me what you mean by this." This response shows active listening and seeks clarification, allowing the nurse to gather more information to better understand the situation and provide appropriate support. It demonstrates empathy and encourages the woman to express her concerns further. Choices A and C are less effective because they do not address the specific issue of the fits the child is having. Choice D is incorrect as it dismisses the woman's emotions and fails to address the underlying problem. Overall, choice B is the best response as it promotes effective communication and understanding between the nurse and the woman.

Correct Answer: B

Rationale: The correct answer is B because asking another nurse to double-check the finding is crucial for validation and ensuring accuracy in assessment. This step helps in confirming the unfamiliar sound and ruling out any potential errors or misinterpretations. It promotes patient safety and effective communication among healthcare providers. Ignoring the sound (Choice A) can lead to overlooking a significant finding that may impact the patient's condition. Documenting and continuing the assessment (Choice C) without validation may result in incomplete information and potential misdiagnosis. Repositioning the patient and listening again (Choice D) may not address the need for confirmation from another healthcare provider.

Correct Answer: A

Rationale: The correct technique is to count the radial pulse for 1 minute if the rhythm is irregular because irregular rhythms may have fluctuations that can affect accuracy. Counting for a full minute provides a more comprehensive assessment of the pulse rate. Choice B is incorrect because multiplying the count by 4 after 15 seconds may not accurately reflect the pulse rate if the rhythm is irregular. Choice C is incorrect because counting for 2 full minutes is unnecessary and can be time-consuming without providing additional benefits in most cases. Choice D is incorrect as multiplying by 6 after 10 seconds is not suitable for irregular rhythms or for patients with cardiac abnormalities.

Correct Answer: C

Rationale: Rationale: Acromegaly is a condition caused by excessive growth hormone production, leading to overgrowth of bones in the face, head, hands, and feet. This results in characteristic features such as enlarged facial bones, hands, and feet. The correct answer is C because it aligns with the typical assessment findings in acromegaly. Summary of other choices: A (Heavy, flattened facial features): This is not consistent with acromegaly, as the condition is characterized by overgrowth of bone rather than flattened features. B (Growth retardation and a delayed onset of puberty): These findings are more indicative of growth hormone deficiency rather than excess, which is seen in acromegaly. D (Increased height and weight and delayed sexual development): While increased height and weight may occur, delayed sexual development is not a common feature of acromegaly.

Correct Answer: A

Rationale: The correct answer is A. The woman's history of diabetes and peripheral vascular disease puts her at increased risk for infection and lesions when trying to remove the corn with scissors. Diabetes can impair wound healing and increase the risk of infection. Peripheral vascular disease can lead to poor circulation, further complicating wound healing. Choices B, C, and D are incorrect because they do not address the specific risks associated with the woman's chronic conditions. Choice B is incorrect as diabetes often causes poor circulation, not increased circulation. Choice C is incorrect as age and visual impairment are not the primary reasons for discouraging the use of scissors. Choice D is incorrect as it focuses on range of motion rather than the specific risks related to diabetes and peripheral vascular disease.