The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply

Correct Answer: A

Rationale: The correct answer is A: Providing tepid sponge bath. This measure helps lower body temperature through evaporation of water from the skin. It is effective in managing fever without causing shivering or discomfort. Ice packs (B) can lead to vasoconstriction and shivering, raising body temperature. Antipyretics (C) are drugs that can reduce fever but may not address the underlying cause. Keeping the room warm (D) can exacerbate fever by hindering heat dissipation.

Correct Answer: B

Rationale: The Heimlich maneuver is performed to clear the airway if a client is choking and cannot speak or breathe after swallowing food. Step 1: Assess the situation and confirm airway obstruction. Step 2: Stand behind the client, wrap your arms around their waist, and deliver upward abdominal thrusts. Step 3: Repeat thrusts until the object is dislodged. Other choices are incorrect as they do not address airway obstruction. A: Increasing medication absorption is not a purpose of the Heimlich maneuver. C: Preventing falls and D: Maintaining extremities in proper position are not related to choking emergencies.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.

Correct Answer: C

Rationale: Rationale for correct answer C: In Hashimoto's thyroiditis, an autoimmune disorder causing hypothyroidism, we expect to see normal to elevated TSH levels due to the pituitary gland stimulating the thyroid to produce more hormones. T4 and T3 levels may be within normal range or slightly decreased. Choice C reflects this pattern with T4 at 22 ug/dl, T3 at 200 ng/dl, and TSH at 0.1 uIU/ml. Summary of why other choices are incorrect: - Choice A: T4 and T3 levels are higher than expected in Hashimoto's thyroiditis, and TSH should be elevated, not stated as normal. - Choice B: An undetectable TSH level is typically seen in hyperthyroidism, not hypothyroidism like Hashimoto's. - Choice D: T4 and T3 levels are significantly lower than expected, and TSH is much higher than typically seen in Hashimoto's

Correct Answer: C

Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.” Rationale: 1. Desmopressin is available in intranasal form for diabetes insipidus. 2. Nasal discharge or blockage may prevent proper absorption of the medication. 3. Instructing the client about this potential issue ensures optimal drug effectiveness. Summary: A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy. B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus. D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.

Correct Answer: B

Rationale: The correct answer is B: Quadriceps setting. After surgery, quadriceps setting exercises are crucial for preventing muscle atrophy and maintaining joint mobility. Bladder control (A) is important but typically not the major early problem. Client education (C) and use of aids for ambulation (D) are important aspects of care but not the primary concern immediately post-surgery. Quadriceps setting helps prevent complications and promote early mobility.

Correct Answer: C

Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.

Correct Answer: C

Rationale: The correct answer is C: "Divided doses produce greater cytotoxic effects on the diseased cells." Dividing the doses of the antimetabolite allows for more consistent levels of the drug in the bloodstream, ensuring sustained exposure to the cancer cells. This continuous exposure enhances the drug's cytotoxic effects, increasing its efficacy in targeting and destroying the diseased cells. Options A and B provide vague or incorrect information, while option D is misleading as antimetabolites do not prevent cell division, but rather disrupt DNA synthesis.

Correct Answer: A

Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process. Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.