Correct Answer: B

Rationale: A priority intervention for a client with multiple myeloma is to include coughing and deep breathing exercises in the plan of care. Multiple myeloma can affect the bone marrow's ability to produce healthy blood cells, including red blood cells, which can lead to anemia. Anemia can cause fatigue and shortness of breath. By encouraging coughing and deep breathing exercises, the nurse can help improve lung function, enhance oxygenation, and prevent potential respiratory complications in the client with multiple myeloma. This intervention is crucial in promoting respiratory health and overall well-being for the client.

Correct Answer: C

Rationale: The patient is most likely experiencing an acute myocardial infarction (MI) based on the presentation of crushing chest pain lasting longer than 20 minutes, diaphoresis, dyspnea, and ST-segment elevation on the ECG. These symptoms are consistent with the classic presentation of an ST-segment elevation myocardial infarction (STEMI), which is a type of acute MI that is characterized by prolonged ischemia leading to myocardial cell death. In this case, the ST-segment elevation in the anterior leads indicates myocardial damage in the corresponding area of the heart supplied by the affected coronary artery. This is a medical emergency that requires urgent intervention to restore blood flow to the affected myocardium and prevent further complications.

Correct Answer: C

Rationale: Antipsychotic medications, especially first-generation antipsychotics, can cause extrapyramidal symptoms (EPS) as an adverse effect. EPS include symptoms such as muscle rigidity, tremors, akathisia (restlessness), and tardive dyskinesia (involuntary movements of the face and body). These symptoms are due to the medications' effects on the dopamine system in the brain. It is crucial for the nurse to monitor the patient closely for EPS because they can be uncomfortable, distressing, and may impact the patient's quality of life and medication adherence. Early recognition and management of EPS are essential to prevent further complications and improve the patient's overall well-being.

Correct Answer: D

Rationale: Cooking foods in a variety that includes meat, dairy products, and beans demonstrates a positive coping index for the family in addressing the protein deficiency and malnutrition in their children. This behavior shows the family's understanding and effort to provide diverse sources of protein, which is essential for addressing protein deficiency. By including different protein-rich foods in their meals, the family is actively working towards improving the nutritional status of their children. This approach aligns with the goal of health education to change knowledge, attitudes, and practices to enhance individual, family, and community health.

Correct Answer: A

Rationale: Ventilator-associated pneumonia (VAP) is a serious complication in patients receiving mechanical ventilation in the ICU. The priority intervention to manage respiratory infection in a patient with VAP is the administration of appropriate antibiotics to target and eliminate the causative pathogens. Broad-spectrum antibiotics are usually initiated empirically to cover a wide range of potential pathogens commonly associated with VAP, such as Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter species. Timely initiation of antibiotic therapy is crucial in improving outcomes and reducing morbidity and mortality associated with VAP. Other interventions like endotracheal suctioning, oral hygiene measures, and early mobilization are also important in preventing complications and promoting recovery, but the primary focus should be on treating the infection with antibiotics.