Pulmonary edema is characterized by:

Correct Answer: C

Rationale: Pulmonary edema is characterized by increased hydrostatic pressure in the pulmonary capillaries and a rise in pulmonary venous pressure, which leads to fluid leaking out of the pulmonary capillaries and into the alveoli. This results in elevated left ventricular end-diastolic pressure, which is a key characteristic of pulmonary edema. Therefore, all of the above alterations (increased hydrostatic pressure, a rise in pulmonary venous pressure, and elevated left ventricular end-diastolic pressure) are seen in pulmonary edema.

Correct Answer: C

Rationale: The most common side effect reported by patients receiving enalapril maleate (Vasotec) is a persistent dry cough. This cough is due to the medication's effect on bradykinin levels in the body, leading to irritation of the respiratory tract and causing the cough. While other side effects such as diarrhea and heartburn may occur, cough is the most frequently reported side effect associated with enalapril maleate. Acne is not a commonly reported side effect of this medication.

Correct Answer: B

Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.

Correct Answer: A

Rationale: In a hospital setting, if shock develops in a client with a spinal cord injury, one of the initial nursing interventions as a precautionary measure is to establish intravenous access by inserting an IV line. This is important for administering fluids, medications, and blood products promptly to help stabilize the client's condition. IV access is crucial in managing shock to ensure proper fluid resuscitation and support the circulatory system to maintain adequate perfusion to vital organs. It also allows for continuous monitoring of the client's hemodynamic status, electrolyte levels, and responses to interventions. Therefore, inserting an IV line is a critical nursing intervention in addressing shock in clients with spinal cord injuries to promote timely and effective management.

Correct Answer: A

Rationale: In a pediatric primary care setting, assessing motor functions during a neurologic examination is crucial for evaluating developmental milestones and detecting any abnormalities early on. Option A, allowing the client to grasp the nurse's hand firmly, is the correct choice because it assesses grip strength, coordination, and muscle tone, providing valuable information about motor function. Option B, checking sensitivity to various stimuli, is more related to sensory function rather than motor function. This step would not directly contribute to assessing motor skills in a neurologic examination. Option C, asking the client to pick up small and large objects between the thumb and forefinger, is more specific to fine motor skills and hand-eye coordination rather than a comprehensive motor function assessment. Option D, asking questions that require cognition and logic, is more aligned with testing cognitive function rather than motor skills, thus not directly relevant to a neurologic examination focusing on motor functions. In an educational context, understanding the rationale behind each step of a neurologic examination is essential for nurses to accurately assess a child's motor function and identify any developmental delays or concerns. By choosing the appropriate assessment techniques, nurses can provide comprehensive care and support to pediatric patients.