Upon admission, a 77-year-old female client presents with confusion, loss of appetite, nausea, vomiting, and headache, with a pulse rate of 43 beats per minute. Which question should the nurse prioritize asking the client or her family?

Correct Answer: D

Rationale: The correct answer is D. The client's symptoms suggest digitalis toxicity, a potentially life-threatening condition that requires immediate attention. Digitalis toxicity can present with symptoms such as anorexia, nausea, vomiting, headache, and bradycardia (low pulse rate). Given the client's presentation, it is crucial to assess for digitalis use as elderly individuals are more susceptible to this type of intoxication. Choices A, B, and C are important aspects to consider during the assessment, but in this scenario, the priority lies in identifying and addressing the potential digitalis toxicity due to the severity of symptoms and the need for prompt intervention.

Correct Answer: B

Rationale: The correct response for the nurse to provide is option B) "Most lumps are benign, but it is always best to come in for an examination." This response is appropriate because it acknowledges the client's concern, provides reassurance about the common benign nature of breast lumps, and emphasizes the importance of seeking professional evaluation to rule out any serious conditions like breast cancer. Option A is incorrect because waiting for a month can delay potential diagnosis and treatment if the lump is indeed concerning. Option C, while attempting to reassure the client, downplays the importance of seeking medical evaluation. Option D is incorrect because menstrual period timing does not prohibit breast self-examinations, and it is important to encourage regular breast self-awareness regardless of the menstrual cycle. In an educational context, it is crucial for nurses to empower clients to take charge of their health by promoting early detection practices like breast self-exams and seeking medical evaluation for any concerning findings. Providing accurate information and support can help alleviate anxiety and promote proactive health behaviors.

Correct Answer: D

Rationale: In the case of an elderly client admitted with bacterial pneumonia, the correct answer is D) Confusion and tachycardia. This is because confusion and tachycardia are common signs and symptoms of pneumonia in the elderly population. Confusion can be a result of hypoxia due to impaired gas exchange in the lungs, while tachycardia can occur as the body tries to compensate for the decreased oxygen levels. Option A) Leukocytosis and febrile are more general signs of infection and inflammation, which can be present in pneumonia but are not as specific to pneumonia in the elderly. Option B) Polycythemia and crackles are not typically associated with pneumonia. Polycythemia refers to an increase in red blood cells, which is not a common finding in pneumonia. Crackles may be present in pneumonia but are not as specific to the elderly population. Option C) Pharyngitis and sputum production are more commonly seen in conditions like upper respiratory tract infections or bronchitis, rather than bacterial pneumonia. In an educational context, it is important for nursing students to understand the specific signs and symptoms of pneumonia in the elderly population as they are at higher risk for complications. Recognizing these signs early on can lead to prompt interventions and improved patient outcomes.

Correct Answer: B

Rationale: Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion. While genetics can play a role, osteoporosis is not solely a genetic disease. Increasing calcium intake, along with vitamin D supplementation and weight-bearing exercise, can help prevent further bone loss by slowing down calcium loss from bones. Estrogen replacement therapy is no longer recommended as a first-line treatment for osteoporosis due to associated risks. Corticosteroid treatment is not typically used as a primary treatment for osteoporosis.

Correct Answer: C

Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.