The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?

Correct Answer: B

Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.

Correct Answer: D

Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications. Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments. Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects. Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.

Correct Answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

Correct Answer: A

Rationale: The most important action for the LPN/LVN to take when a client with a history of diabetes mellitus experiences symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps assess the severity of hyperglycemia and guides further interventions. Encouraging the client to increase fluid intake (Choice B) may exacerbate the symptoms by further diluting the blood glucose concentration. Administering insulin as prescribed (Choice C) should be done based on the healthcare provider's orders and after assessing the blood glucose levels. Assessing the client's urine output (Choice D) is important but not the most immediate action needed in this scenario.

Correct Answer: C

Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.

Correct Answer: C

Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.

Correct Answer: A

Rationale: The correct answer is A: Fidelity. Fidelity in nursing ethics involves keeping promises and being faithful to commitments, demonstrating reliability and trustworthiness. In this scenario, the nurse is exemplifying fidelity by returning promptly to the client as promised. Choice B, Autonomy, refers to respecting a patient's right to make their own decisions, not relevant in this situation. Choice C, Beneficence, involves the duty to act in the best interest of the patient, which is not the primary focus here. Choice D, Justice, pertains to fairness and equity in the distribution of healthcare resources, not applicable to the nurse's actions in this case.

Correct Answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

Correct Answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.