The nurse is preparing to examine an infant. Which of the following actions is the most appropriate to perform first?

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.

Correct Answer: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: B

Rationale: The correct answer is B: Shakiness and dizziness. Hypoglycemia is characterized by low blood sugar levels, leading to symptoms such as shakiness and dizziness. This is because the brain requires glucose for energy, and when levels drop too low, these symptoms can occur. Increased thirst and urination (A) are more indicative of hyperglycemia, where blood sugar levels are too high. Blurred vision and headaches (C) can be symptoms of both hyperglycemia and hypoglycemia but are less specific to hypoglycemia. Fatigue and weight loss (D) are not typical symptoms of hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.

Correct Answer: C

Rationale: The correct answer is C. The nurse should prevent infiltration of calcium to avoid tissue necrosis and sloughing. Infiltration of calcium can lead to severe tissue damage due to its caustic nature. Therefore, the nurse should be vigilant in monitoring the IV site and ensuring proper placement to prevent this complication. Choice A is incorrect because infusing hypertonic solutions rapidly can lead to fluid overload and electrolyte imbalances. Choice B is incorrect because exceeding the recommended amount of potassium per liter of fluid can result in hyperkalemia, which can be dangerous. Choice D is incorrect because calcium does not diminish digitalis's action; in fact, calcium can potentiate the effects of digitalis.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. This is the priority intervention because severe dehydration requires immediate fluid replacement to restore fluid balance and prevent further complications. IV fluids are the most rapid and effective way to rehydrate a severely dehydrated client. Monitoring vital signs (B) and blood pressure (D) are important, but administering IV fluids takes precedence. Encouraging oral fluids (C) may not be sufficient for a client with severe dehydration who may not be able to adequately absorb fluids orally.

Correct Answer: A

Rationale: The correct answer is A: Administer thrombolytics. Thrombolytics help dissolve blood clots causing the stroke, restoring blood flow to the brain. This intervention is time-sensitive to prevent further brain damage. Administering aspirin (B) is important but not the priority over thrombolytics. Performing an ECG (C) assesses heart function, not the immediate intervention for stroke. Administering corticosteroids (D) is not indicated in acute stroke management.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.

Correct Answer: D

Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.