What is the most appropriate action for a nurse when caring for a client with severe hypothermia?

Correct Answer: A

Rationale: The correct answer is A: Administer warm IV fluids. This is because in severe hypothermia, the body's core temperature drops dangerously low, leading to decreased circulation and potential organ failure. Administering warm IV fluids helps to gradually raise the core temperature and prevent further complications. Choice B (Warming the client with a heating pad) can cause rewarming shock and skin burns. Choice C (Placing the client in a supine position) is not directly related to treating hypothermia. Choice D (Administering analgesics) is not the priority in treating severe hypothermia.

Correct Answer: B

Rationale: The correct answer is B. When a client is moving towards illness and premature death, signs and symptoms typically start to manifest. These can include physical changes, abnormal lab results, or new onset of health issues. This serves as a direct indication of the client's deteriorating health status. Choices A, C, and D are incorrect because stopping wellness-promoting activities (A) could simply be due to lack of motivation, starting to exercise (C) may not necessarily indicate illness progression, and verbalizing anxiety over medication costs (D) is not a direct indicator of impending illness and premature death.

Correct Answer: B

Rationale: The correct answer is B because lorazepam is a fast-acting medication that can help reduce the intensity of a panic attack quickly. It works by calming the central nervous system and reducing anxiety symptoms. Encouraging slow, deep breathing (choice A) can be helpful, but it may not be as effective as medication in stopping a severe panic attack. Lying down (choice C) can provide comfort but does not address the underlying physiological response. Breathing into a paper bag (choice D) can actually be harmful as it may lead to hyperventilation.

Correct Answer: B

Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.

Correct Answer: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.

Correct Answer: B

Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.

Correct Answer: D

Rationale: The correct answer is D because spirituality involves seeking meaning in one's life, which can provide a sense of purpose and fulfillment. This search is personal and introspective, focusing on individual values and beliefs. A, B, and C are incorrect because spirituality is not solely about belief in a supreme being, adherence to a specific system of beliefs, or the pursuit of life after death. Rather, it is about finding meaning, connection, and inner peace in one's existence.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Limiting alcohol intake reduces blood pressure. Reducing sodium intake also helps manage hypertension. Alcohol can increase blood pressure, while sodium can lead to fluid retention. The patient's statement shows understanding of the importance of both factors in managing hypertension. Other Choices: A: Increasing sodium intake worsens fluid retention and hypertension. C: Processed foods are often high in sodium and unhealthy fats, worsening hypertension. D: Reducing exercise can lead to weight gain and increased blood pressure, contrary to managing hypertension.