During the first 12 hours of hospitalization you notice that the patient's temperature, pulse, and respiration are showing a steady rise. Petechiae are developing on her chest and she is becoming confused. After notifying the physician, what is the highest priority of care?

Correct Answer: B

Rationale: In this scenario, the highest priority of care is to continue close monitoring of vital signs and mental status (Option B). This is crucial because the patient is exhibiting signs of a deteriorating condition, including a rise in temperature, pulse, respiration, petechiae, and confusion. Close monitoring will help detect any further changes in the patient's condition promptly, allowing for timely intervention and treatment. Assessing for further signs of infection (Option A) is important in the overall care of the patient, but it is not the highest priority at this moment. The patient is already showing concerning symptoms that require immediate attention. Encouraging fluids and reality orientation measures (Option C) and increasing ventilation by the use of blow bottles (Option D) are not the most appropriate actions to address the current critical situation the patient is facing. These interventions do not directly address the urgent need to monitor and manage the escalating symptoms effectively. From an educational standpoint, this question highlights the importance of prioritizing care based on the patient's condition and the urgency of the situation. It underscores the significance of prompt assessment and monitoring in identifying changes in a patient's status and initiating timely interventions to ensure patient safety and well-being.

Correct Answer: C

Rationale: In the context of a health assessment focusing on the neurological system, the question "Do you have any difficulty chewing or swallowing?" (Option C) would be especially important to ask when taking Mr. Sands' health history. This is because difficulties in chewing or swallowing can be indicative of neurological issues such as cranial nerve dysfunction, stroke, or other conditions affecting the brain's control over these functions. Option A, asking about back pain or flank tenderness, is more relevant to musculoskeletal or renal system assessments, not specifically neurological assessments. Option B, inquiring about the effect of cold on hands, is more related to vascular or peripheral nervous system issues rather than the neurological system. Option D, asking about joint tenderness or stiffness, is more pertinent to musculoskeletal or rheumatologic assessments rather than neurological evaluations. Educationally, understanding the relevance of specific questions in a health history to different body systems is crucial for effective assessment and diagnosis. This question highlights the importance of recognizing neurological symptoms that may present in seemingly unrelated issues like chewing or swallowing difficulties. It underscores the need for a comprehensive and systematic approach to health assessments to identify potential neurological problems early.

Correct Answer: D

Rationale: In the context of initial treatment for a patient with a fracture, the correct answer is D) Immobilization of the area. Immobilization is crucial to prevent further damage, promote proper healing, and reduce pain. By stabilizing the fracture site through immobilization, the risk of displacement or further injury is minimized. This allows the body to initiate the healing process effectively. Option A) Surgical reduction of the fracture involves a more invasive approach and is usually reserved for complex fractures or cases where conservative management fails. Option B) Insertion of internal fixation device is a surgical intervention that may be needed in certain fractures but is not typically the initial treatment. Understanding the importance of prompt immobilization in the initial phase of fracture management is essential for healthcare providers, especially nurses and allied health professionals involved in patient care. It ensures that they can provide timely and appropriate interventions to optimize patient outcomes and prevent complications. By grasping this concept, healthcare professionals can contribute to the overall well-being and recovery of patients with fractures.

Correct Answer: B

Rationale: In the context of health assessment and the neurological system, understanding the importance of maintaining muscle strength and bone mass in older adults is crucial. The correct answer to the question is B) Maintaining an active lifestyle. This option is correct because physical activity, including weight-bearing exercises and resistance training, is essential for preserving muscle strength and bone mass as we age. Regular exercise helps to stimulate bone growth, maintain muscle mass, and improve overall balance and coordination, reducing the risk of falls and fractures in older adults. Option A) Maintaining an adequate calcium intake is important for bone health, but without physical activity, the body may not effectively utilize the calcium for maintaining bone density. It is a part of a holistic approach to bone health but alone is not sufficient to delay the decline in muscle strength and bone mass. Option C) Maintaining a low-activity lifestyle after the age of 35 is detrimental to muscle and bone health. Lack of physical activity can lead to muscle atrophy, decreased bone density, and overall decline in physical function. Option D) Reducing calcium intake after the age of 60 is not advisable as older adults actually require more calcium to maintain bone health due to age-related changes in bone density and absorption. Educationally, it is essential to emphasize to students and healthcare professionals the importance of physical activity in promoting healthy aging and preventing musculoskeletal issues in older adults. Encouraging regular exercise routines tailored to individual needs and abilities can significantly impact the quality of life and independence of older individuals. It is crucial to integrate this knowledge into health assessments and care planning for older adult populations to promote optimal health outcomes.

Correct Answer: A

Rationale: The correct answer is A) Strain. A strain is an injury to a muscle or tendon due to overstretching or overuse. In this scenario, the client developed inflammation, tenderness, and muscle spasms after overstressing her arm muscles, which are common symptoms of a strain. Option B) Contusion refers to a bruise caused by blunt force trauma, not by overstretching, so it is incorrect in this context. Option C) Sprain involves the stretching or tearing of ligaments, not muscles or tendons, so it is not the most likely problem in this case. Option D) Avulsion fracture occurs when a tendon or ligament pulls off a piece of bone, which is different from the client's presentation of muscle overstretching. Educationally, understanding the differences between strain, contusion, sprain, and avulsion fracture is crucial for healthcare providers, especially nurses, to accurately assess and diagnose musculoskeletal injuries. Recognizing the specific characteristics and causes of each type of injury helps in providing appropriate care and treatment to clients.