A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?

Correct Answer: C

Rationale: The correct answer is C: "You are upset that this incident has brought you here." This response acknowledges the client's feelings of anger and validates her emotions, showing empathy and understanding. It demonstrates active listening and therapeutic communication, which is crucial in building trust and rapport with the client. Choice A is incorrect as it dismisses the client's feelings of anger and invalidates her emotions by shifting the focus to being grateful instead. Choice B is incorrect as it minimizes the client's emotional response by focusing on the material aspect of the situation rather than addressing her feelings. Choice D is incorrect as it does not address the client's emotional state and is a closed-ended question that does not encourage further discussion or exploration of the client's feelings.

Correct Answer: C

Rationale: The correct answer is C: Oxygen saturation of 88%. In COPD patients, low oxygen saturation indicates inadequate gas exchange and potential respiratory distress. Oxygen saturation below 90% requires immediate intervention to prevent hypoxemia. A: Barrel-shaped chest is a common finding in COPD due to hyperinflation, but it is not a critical indicator of acute exacerbation. B: Use of accessory muscles suggests increased work of breathing but may not be as urgent as low oxygen saturation. D: Respiratory rate is within normal range, so it is less concerning than the low oxygen saturation.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Digoxin is a medication that can cause bradycardia as a side effect. 2. Instructing the client to take their pulse before each dose is crucial to monitor for bradycardia. 3. Holding the medication if the pulse is below 60 beats per minute helps prevent potential adverse effects. 4. This instruction ensures the client's safety and adherence to the prescribed regimen. Summary: - Choice B is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin. - Choice C is incorrect as taking digoxin with a high-fiber meal may affect absorption negatively. - Choice D is incorrect because skipping a dose based on dizziness or lightheadedness may lead to suboptimal treatment outcomes.

Correct Answer: A

Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, there is inflammation of the pancreas leading to elevated serum amylase levels. Amylase is an enzyme produced by the pancreas, and increased levels indicate pancreatic injury. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis. Choice B: Serum sodium, and Choice D: Serum potassium may be affected in pancreatitis due to fluid shifts, but they are not specific markers for pancreatitis. Choice C: Serum calcium may also be affected in pancreatitis, but monitoring serum calcium is not as crucial as monitoring serum amylase for diagnosing and managing acute pancreatitis.

Correct Answer: B

Rationale: The correct answer is B: Report any weight gain of more than 2 pounds in a day. This instruction is crucial for a client with heart failure taking furosemide as sudden weight gain can indicate fluid retention, which can worsen heart failure. Monitoring weight daily can help detect early signs of fluid overload. A: Taking the medication before bedtime is not a critical instruction for furosemide as it is usually taken in the morning to prevent nocturia. C: Increasing intake of high-sodium foods contradicts the purpose of furosemide, which is a diuretic used to reduce fluid retention by promoting diuresis. D: Limiting fluid intake to less than 1 liter per day can lead to dehydration and electrolyte imbalances, which can be harmful for a client with heart failure.