Correct Answer: D

Rationale: Anticoagulant therapy, specifically heparin, is commonly used as the initial treatment for pulmonary embolism (PE) because it inhibits the formation of additional clots by altering the synthesis of vitamin K-dependent clotting factors. Heparin works quickly and can be administered intravenously to rapidly prevent the clot from growing in size. Warfarin, another anticoagulant, is generally started after heparin therapy is initiated to provide long-term anticoagulation. Major hemorrhage is a potential side effect of anticoagulant therapy, but it is not considered common. The initiation of heparin and warfarin (Coumadin) at the same time is not standard practice due to the differing mechanisms of action and monitoring required for each medication. Anticoagulant therapy is considered first-line treatment for PE, not second-line.

Correct Answer: D

Rationale: In older adults, particularly those over 65 years of age, atypical symptoms of a myocardial infarction may occur. Abdominal pain is considered an atypical age-related warning sign because older adults may present with subtle or nonspecific symptoms, such as discomfort or pain in the abdomen, rather than the classic chest pain associated with a heart attack. This atypical presentation can lead to delays in seeking medical attention and diagnosis, which can have serious consequences for the client. Therefore, it is important for the nurse to educate older clients about the possibility of experiencing atypical symptoms, such as abdominal pain, in the context of a myocardial infarction.

Correct Answer: A

Rationale: Supporting a stroke client's sensorimotor needs involves encouraging independence and rehabilitation of the affected side. By encouraging the use of the nonaffected arm for self-care activities like feeding, bathing, and dressing, the nurse is promoting sensorimotor development and function in the affected arm. This intervention will help the client regain strength, coordination, and functionality in the affected arm, which is crucial for their overall recovery and independence. Encouraging the client to actively engage the affected arm promotes neuroplasticity and can improve motor function over time.

Correct Answer: B

Rationale: HELLP syndrome is a serious complication of pregnancy characterized by Hemolysis (H), Elevated Liver enzymes (EL), and a Low Platelet count (LP). Therefore, the correct laboratory finding consistent with the diagnosis of HELLP syndrome is hemolysis. This can be indicated by an elevated lactate dehydrogenase (LDH) level, low haptoglobin, elevated bilirubin, and the presence of schistocytes on a blood smear. The other options (A, C, and D) do not align with the classic presentation of HELLP syndrome.

Correct Answer: D

Rationale: While it is positive that the client has taken the initiative to research the procedure online, it is essential for the nurse to assess the client's actual understanding and ability to perform the fingerstick blood sugar analysis correctly. The best course of action would be for the nurse to watch the client perform a return demonstration of the skill. This will allow the nurse to provide real-time feedback, correct any errors, and ensure that the client is performing the procedure accurately and safely. Watching a return demonstration is a critical step in the client's learning process, as it confirms their comprehension and ability to apply the information effectively. It also enables the nurse to address any misconceptions or gaps in knowledge that may not have been evident from the client's statement alone.