How should a nurse document a mass in the foot causing difficulty walking?

Correct Answer: D

Rationale: The correct answer is D: Morton's neuroma. This condition typically presents as a mass in the foot causing pain and difficulty walking. The nurse should document it as Morton's neuroma because it specifically refers to a benign growth of nerve tissue between the toes. Plantar fasciitis (A) is inflammation of the tissue on the bottom of the foot, not a mass. Hallux valgus (B) is a bunion deformity of the big toe joint. Hammertoe (C) is a deformity of the toe joints. Therefore, the correct choice is D as it aligns with the description of a mass causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Administer thrombolytics. Thrombolytics help dissolve blood clots causing the stroke, restoring blood flow to the brain. This intervention is time-sensitive to prevent further brain damage. Administering aspirin (B) is important but not the priority over thrombolytics. Performing an ECG (C) assesses heart function, not the immediate intervention for stroke. Administering corticosteroids (D) is not indicated in acute stroke management.

Correct Answer: C

Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.

Correct Answer: C

Rationale: The correct answer is C: decrease maternal fluids. When fetal distress is indicated, decreasing maternal fluids helps prevent further stress on the fetus by reducing the volume of amniotic fluid. This can help improve blood flow to the placenta and oxygen delivery to the baby. Increasing maternal fluids (choice A) can worsen the situation by potentially increasing amniotic fluid volume and further compromising fetal oxygenation. Administering oxygen (choice B) is important to improve oxygen supply to the fetus. Turning the mother (choice D) can help relieve pressure on the baby but is not the primary action when fetal distress is indicated.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first priority in caring for a client experiencing a stroke is to ensure adequate oxygen supply to the brain, as lack of oxygen can lead to further brain damage. Administering oxygen helps improve oxygenation and can prevent complications. Administering morphine (B) is not recommended as it can mask symptoms and delay diagnosis. Administering IV fluids (C) may be necessary but is not the first priority. Administering fibrinolytics (D) is a time-sensitive intervention for ischemic stroke but should be done after proper evaluation and confirmation of the type of stroke.

Correct Answer: A

Rationale: The correct answer is A: Administer fluids. In hypovolemic shock, the primary issue is a lack of circulating blood volume. Administering fluids helps to restore blood volume and improve perfusion to vital organs, addressing the underlying cause of shock. Vasopressors (B) are used in distributive shock, sodium bicarbonate (C) is used for metabolic acidosis, and corticosteroids (D) are typically not indicated in hypovolemic shock. Administering fluids is the most important intervention to stabilize the client's condition in hypovolemic shock.

Correct Answer: B

Rationale: The correct answer is B, Hepatic encephalopathy. In cirrhosis, the liver is unable to detoxify ammonia, leading to its accumulation and causing neurological symptoms. Monitoring for signs such as confusion, altered mental status, and asterixis is crucial. Acute renal failure (A) is not directly related to cirrhosis but may occur as a complication. Acute pancreatitis (C) is not a typical complication of cirrhosis. COPD (D) is a respiratory condition and not directly associated with cirrhosis.

Correct Answer: A

Rationale: The correct answer is A: Apply a splint. This is the first step because immobilizing the affected limb helps prevent further injury and reduces pain. Administering fluids (B) and oxygen (C) are important but not the priority in this situation. Elevating the limb (D) can wait until the fracture is stabilized.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority nursing action for a client with an electrical burn because pain management is crucial in providing comfort and reducing distress. Pain relief helps the client to relax, promotes healing, and aids in overall recovery. Administering pain relief should be the first step to ensure the client's well-being. Summary: - B: Administering oxygen may be necessary for respiratory support in some cases but is not the priority over pain relief. - C: Applying sterile dressings is important for wound care but should come after addressing pain. - D: Administering beta blockers is not indicated as the priority action for an electrical burn.