The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. Which of the following would be an appropriate response?

Correct Answer: D

Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.

Correct Answer: C

Rationale: The correct answer is C because asking open-ended questions helps the patient express their feelings without feeling pressured. This approach allows the patient to share at their own pace and comfort level. Choice A may make the patient feel uncomfortable or pressured. Choice B may not address the underlying issue of the patient's avoidance of eye contact. Choice D is more direct and may not be effective if the patient is not ready to discuss their emotions. Ultimately, using open-ended questions promotes a safe and supportive environment for the patient to open up willingly.

Correct Answer: D

Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When caring for a client with suspected hypoglycemia, the first priority is to raise their blood sugar levels quickly to prevent potential complications such as seizures or loss of consciousness. Administering glucose helps to rapidly increase blood sugar levels and alleviate symptoms. The other choices (B: Administer insulin, C: Place the client in a supine position, D: Administer IV fluids) are incorrect because administering insulin can further lower blood sugar levels, placing the client in a supine position may not address the immediate issue of low blood sugar, and administering IV fluids does not directly address the hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A. Older adults may have a longer story to tell due to their wealth of life experiences. This can include medical history, family background, and personal stories that may impact their health. It is important for the nurse to gather all relevant information to provide appropriate care. Choice B is incorrect because not all older adults are lonely, and the reason for a longer interview is not solely based on the need for social interaction. Choice C is incorrect because while some older adults may experience cognitive decline, it is not a blanket statement that all older adults lose mental abilities. Choice D is incorrect because hearing loss is not a universal issue among older adults, and assuming so can lead to ageist stereotypes.

Correct Answer: C

Rationale: Step 1: Nutrition is important for overall health and healing in a client in Buck's traction. Step 2: Elimination is necessary to prevent complications such as constipation. Step 3: Comfort measures help alleviate pain and promote well-being. Step 4: Safety measures ensure the client's well-being during traction. Step 5: ROM exercises are not recommended to prevent displacement of traction. Transportation and isotonic exercises are not directly related to Buck's traction care.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In CKD, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac complications. Hyperkalemia is a common and critical complication in CKD patients. B: Hypokalemia is unlikely in CKD as the kidneys typically retain potassium. C: Hyperglycemia is more commonly associated with diabetes rather than CKD. D: Hypercalcemia is not a common complication of CKD; in fact, CKD often leads to lower calcium levels due to impaired activation of vitamin D.

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.