The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes which priority intervention in the plan of care?

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: D

Rationale: Non-maleficence is the ethical principle that emphasizes the obligation to avoid causing harm to patients. In this scenario, the ER nurse clarifies the doctor's prescription to ensure the correct dosage of the pain medication based on the pain scale assessment and the patient's age. By doing so, the nurse is ensuring that the medication is safe and effective for the patient, thus adhering to the principle of non-maleficence. This action demonstrates the nurse's commitment to preventing harm and promoting the well-being of the patient through proper medication management.

Correct Answer: C

Rationale: Dry cough is the most commonly reported adverse effect associated with lisinopril therapy. Lisinopril is an ACE inhibitor, and the mechanism behind the cough is not completely understood but is thought to be related to the accumulation of bradykinin and substance P. This annoying dry cough can be a persistent issue for some patients on lisinopril, and it typically resolves once the medication is discontinued. Patients who experience this side effect should not ignore it and should consult their healthcare provider for further evaluation and possible alternative medication options. Hyperkalemia, hypertension, and bradycardia are not commonly associated adverse effects of lisinopril therapy.

Correct Answer: B

Rationale: In Stage I of Hodgkin's disease, the most commonly seen early symptom is usually unexplained fever and night sweats. Other common symptoms at this stage may include unexplained weight loss, itching, and enlarged lymph nodes in the neck, underarms, or groin. Chest and back pains, subnormal body temperature, and swelling of extremities are not typically early indicators of Stage I Hodgkin's disease.

Correct Answer: D

Rationale: A subarachnoid hemorrhage is characterized by bleeding within the subarachnoid space, the area between the arachnoid mater and the pia mater surrounding the brain. Patients typically present with a sudden-onset severe headache, altered mental status, and focal neurological deficits due to the mass effect of the blood in the subarachnoid space. Imaging, such as a CT scan, can confirm the presence of the hemorrhagic lesion. Ischemic stroke results from a blockage in the blood vessels supplying the brain, leading to tissue infarction and neurological deficits. Subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, commonly seen following head trauma. Intracerebral hemorrhage involves bleeding within the brain tissue itself, often leading to focal neurological deficits.

Correct Answer: C

Rationale: The described presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is characteristic of fungal keratitis. Fungal keratitis typically presents with these specific features on clinical examination.

Correct Answer: C

Rationale: The correct next step after positioning the child is to drop the medicine into the ear canal. This is typically the next step in administering ear drops for a child. The cleaning and positioning steps are to prepare the ear for receiving the medication. Dropping the medicine into the ear canal ensures that the medication can reach the affected area effectively. Once the medicine is dropped into the ear canal, it is important to follow any additional instructions provided by the healthcare provider regarding keeping the ear in a certain position or any other post-administration care steps.

Correct Answer: A

Rationale: Developing a routine with the patient to balance her studies and rest needs is the most appropriate intervention to promote rest. This approach considers the patient's responsibilities and can help her organize her time effectively to ensure she gets adequate rest while managing her studies. It acknowledges the importance of rest without completely disregarding the patient's other commitments, ultimately fostering a balanced approach to self-care. This intervention is patient-centered and collaborative, empowering the patient to take an active role in prioritizing rest alongside her educational responsibilities.

Correct Answer: C

Rationale: The priority item that should be placed at the newborn's bedside is a blood pressure cuff. Monitoring the newborn's blood pressure is crucial in the NICU, as it helps assess the baby's cardiovascular function and overall well-being. Blood pressure changes can be an early indication of potential health issues, so having a blood pressure cuff readily available allows for timely monitoring and intervention if necessary. The other items listed (specific gravity urinometer, rectal thermometer, bottle of sterile normal saline) are also important in neonatal care, but monitoring blood pressure takes precedence in this scenario.