How do nurses facilitate the achievement of high-level wellness with a client?

Correct Answer: C

Rationale: The correct answer is C because promoting health in the client is essential in achieving high-level wellness. Nurses play a crucial role in educating, empowering, and supporting clients in making healthy lifestyle choices. By promoting health, nurses help clients prevent illness, maintain optimal well-being, and improve their overall quality of life. Encouraging appointment attendance (choice A) is important but not solely focused on wellness promotion. Providing information on alternative treatments (choice B) is valuable but may not directly contribute to high-level wellness. Providing good client care (choice D) is a fundamental nursing responsibility, but it does not specifically address the promotion of health and wellness.

Correct Answer: A

Rationale: The correct answer is A: Administer antipyretics. The nurse should first address the fever to prevent potential complications. Antipyretics help reduce fever and discomfort quickly. Monitoring vital signs (B) is important but treating the fever takes precedence. Administering fluids (C) is essential, but addressing the fever is the priority. Administering IV antibiotics (D) may be necessary if the fever is due to infection, but confirming the cause and starting treatment can come after addressing the fever.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. After a craniotomy, the client may experience decreased oxygen levels due to the surgical procedure, anesthesia, or potential complications. Administering oxygen helps ensure adequate oxygenation to the brain and tissues. Placing the client in a supine or Trendelenburg position can increase intracranial pressure, which is contraindicated post-craniotomy. Monitoring for arrhythmias is important, but ensuring oxygenation takes precedence as hypoxia can have immediate detrimental effects on brain function.

Correct Answer: B

Rationale: The correct answer is B: Monitor abdominal pain. This is the priority assessment for a client with acute pancreatitis because it helps determine the severity of the condition and guides the treatment plan. Abdominal pain is a key symptom of pancreatitis and monitoring its intensity, location, and changes over time is crucial. Assessing vital signs (choice A) is important but secondary to monitoring pain. Monitoring serum amylase levels (choice C) is relevant for diagnosis but not immediate priority. Performing a CT scan (choice D) may be necessary later for further evaluation but is not the initial priority in managing acute pancreatitis.

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional period before menopause when a woman's body begins to produce less estrogen. This can lead to irregular menstrual cycles and other symptoms such as hot flashes, night sweats, and mood changes. Assessing for symptoms of perimenopause in a woman reporting irregular menses for six months is appropriate as it aligns with the timing and characteristics of this phase. Explanation for incorrect choices: A: Climacteric refers to the period of menopausal transition and is not specific to the symptoms mentioned in the scenario. B: Menopause is the cessation of menstrual periods for 12 consecutive months and is not typically associated with irregular menses. D: Postmenopause is the period after menopause has been established for at least 12 months and irregular menses would not be expected during this phase.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Preventing infiltration of calcium is crucial to avoid tissue necrosis and sloughing. 2. Infiltration of calcium can lead to severe tissue damage and potential harm to the patient. 3. Monitoring for signs of infiltration during administration of electrolyte solutions is essential. 4. Administering calcium-containing solutions cautiously can prevent serious complications. 5. Ensuring proper placement of the IV line and monitoring for any signs of infiltration is key. Summary: A: Infusing hypertonic solutions rapidly can lead to adverse effects, such as fluid overload. B: Limiting potassium to 80 mEq per liter is important, but not directly related to preventing calcium infiltration. D: Reevaluating digitalis dosage is important in clients receiving electrolyte solutions but not directly related to preventing calcium infiltration.

Correct Answer: D

Rationale: The correct answer is D because breast implants can hinder mammography by obscuring the view of breast tissue, making it difficult to detect abnormalities like masses. This is due to the implants blocking the x-ray machine's view. Choice A is incorrect as discomfort is not the primary reason for interference. Choice B is incorrect as breast implants are not a contraindication to mammography but can complicate the process. Choice C is incorrect as implants are designed to be secure and are not likely to be dislodged during a mammogram.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.