Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:

Correct Answer: A

Rationale: The correct answer is A: Turn him frequently. Turning the client frequently helps redistribute pressure, reducing the risk of pressure ulcers. This promotes circulation and relieves pressure on specific areas. Passive ROM exercises (B) are important for maintaining joint mobility but do not directly prevent pressure ulcers. Reducing fluid intake (C) is not recommended as hydration is crucial for skin health. Using a footboard (D) may help with positioning but is not as effective as regular turning for preventing pressure ulcers.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): Osteoarthritis is the most common form of arthritis, affecting millions worldwide. It is characterized by the breakdown of cartilage in joints. This statement is correct as it accurately reflects the prevalence and impact of osteoarthritis. Summary of Incorrect Choices: A: Osteoarthritis can indeed be debilitating, especially in advanced cases, affecting mobility and quality of life. B: Osteoarthritis is not rare; it is prevalent, particularly in older populations. D: While osteoarthritis is more common in older adults, it can also affect people of all ages, including younger individuals due to factors like joint injury or genetics.

Correct Answer: C

Rationale: The correct answer is C. Regular insulin typically has an onset of action around 30 minutes after administration, with its peak action occurring around 2-4 hours later. In this case, the insulin was administered at 2 p.m., so the onset would be around 2:30 p.m. and the peak around 4 p.m. Option A is incorrect because the onset of action is not immediate at 2 p.m. and peak action happens later. Option B is incorrect as the onset would be closer to 2:30 p.m. Option D is incorrect as the peak action would not occur 2 hours after onset. Therefore, option C is the most appropriate based on the pharmacokinetics of regular insulin.

Correct Answer: D

Rationale: The correct answer is D: Spontaneous pneumothorax. In this scenario, the decreased to absent breath sounds on the right side indicate a possible lung collapse, which is characteristic of a spontaneous pneumothorax. This condition occurs when air enters the pleural space, causing the lung to collapse. The absence of breath sounds is due to the lack of air movement in the affected lung. Acute asthma (choice A) typically presents with wheezing and prolonged expiration. Chronic bronchitis (choice B) is characterized by productive cough and wheezing. Pneumonia (choice C) would present with crackles and increased breath sounds in the affected area.

Correct Answer: C

Rationale: The correct answer is C: Essential thrombocytopenia. Clients with SLE are at risk for developing various blood dyscrasias, including thrombocytopenia (low platelet count). Thrombocytopenia can lead to an increased risk of bleeding, which is important for the client to be aware of. Dressler's syndrome (A) is a post-myocardial infarction syndrome and not directly related to SLE. Polycythemia (B) is an increase in red blood cells, not typically associated with SLE. Von Willebrand's disease (D) is a bleeding disorder due to a deficiency in von Willebrand factor, but it is not commonly seen in SLE.