What is the first priority when caring for a client who is experiencing a stroke?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first priority in caring for a client experiencing a stroke is to ensure adequate oxygen supply to the brain, as lack of oxygen can lead to further brain damage. Administering oxygen helps improve oxygenation and can prevent complications. Administering morphine (B) is not recommended as it can mask symptoms and delay diagnosis. Administering IV fluids (C) may be necessary but is not the first priority. Administering fibrinolytics (D) is a time-sensitive intervention for ischemic stroke but should be done after proper evaluation and confirmation of the type of stroke.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Correct Answer: B

Rationale: The correct answer is B: Alopecia. MOPP therapy for Hodgkin's disease commonly causes hair loss (alopecia), which directly affects body image. This is due to the impact on a person's physical appearance, leading to changes in self-perception and confidence. Cushingoid appearance (A) is a side effect of prolonged corticosteroid use, not typically associated with MOPP therapy. Temporary or permanent sterility (C) and pathologic fractures (D) are potential side effects of other cancer treatments but are not directly related to altering body image.

Correct Answer: D

Rationale: The correct answer is D: To treat human responses. This goal aligns with the nursing profession's focus on addressing the holistic needs of individuals. Nurses aim to understand and manage patients' emotional, physical, and psychological responses to illness or treatment. By treating human responses, nurses can improve overall well-being. A: Providing cost-effective care is important but not a broad goal within nursing. It is a component of efficient healthcare delivery. B: Forming broad nursing diagnoses is a part of the nursing process, not a broad goal in itself. C: Promoting self-care is crucial in nursing practice, but it is more of a specific intervention rather than a broad goal encompassing the entire profession.

Correct Answer: D

Rationale: The correct answer is D: Morton's neuroma. This condition typically presents as a mass in the foot causing pain and difficulty walking. The nurse should document it as Morton's neuroma because it specifically refers to a benign growth of nerve tissue between the toes. Plantar fasciitis (A) is inflammation of the tissue on the bottom of the foot, not a mass. Hallux valgus (B) is a bunion deformity of the big toe joint. Hammertoe (C) is a deformity of the toe joints. Therefore, the correct choice is D as it aligns with the description of a mass causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are the primary treatment for DVT as they prevent blood clots from getting bigger and reduce the risk of new clots forming. This helps prevent complications like pulmonary embolism. Elevating the leg and applying compression (option B) can help with symptoms but do not address the underlying cause. Providing anticoagulant therapy (option C) is similar to the correct answer but lacks specificity. Applying compression stockings (option D) can help prevent complications but do not treat the existing clot.

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: D

Rationale: The correct answer is D because an episodic history is most appropriate for acute, short-term conditions like cold and flu symptoms seen in an outpatient clinic. This type of history focuses on the current problem and recent events leading up to it. Choice A involves a long-term care facility, which would require a more comprehensive history. Choice B describes a sudden severe symptom, which would prompt an urgent or emergent history. Choice C involves an upcoming surgical procedure, which would require a preoperative history. Therefore, option D is the most appropriate for an episodic history as it aligns with the acute nature of the condition and the focus on the current issue.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. Dehydration and hypotension indicate fluid loss, which can lead to organ damage and shock. Administering IV fluids helps restore blood volume and improve blood pressure. Monitoring blood pressure (B) is important but addressing the underlying issue of fluid loss is crucial. Administering antihypertensive medications (C) would further lower blood pressure, worsening hypotension. Administering diuretics (D) would exacerbate fluid loss, worsening dehydration and hypotension.