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: A

Rationale: The correct answer is A: Administer epinephrine. This is the first action because epinephrine is the primary treatment for anaphylaxis, a severe allergic reaction that can be life-threatening. It works quickly to reverse the symptoms by constricting blood vessels and opening airways. Administering epinephrine promptly can prevent progression to severe complications such as respiratory distress or cardiovascular collapse. Placing the client in a supine position and administering oxygen (B) may be necessary but should not delay the administration of epinephrine. Administering fluids (C) may help maintain blood pressure but is not the priority in the acute phase of anaphylaxis. Antihistamines (D) are not effective for treating the severe symptoms of anaphylaxis and should not be the first-line treatment.

Correct Answer: B

Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, maintaining adequate hydration is crucial to support kidney function and prevent further damage. IV fluids help improve renal perfusion and promote urine output. Hemodialysis may be necessary in severe cases but initial intervention is fluid resuscitation. Administering pain relief or morphine is not the priority in acute renal failure as addressing hydration status takes precedence over pain management.

Correct Answer: A

Rationale: The correct answer is A because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues is "A: Impaired Physical Mobility." This diagnosis accurately reflects the client's limited ability to move due to the disease's impact on coordination and muscle control. Impaired Physical Mobility addresses the specific issue of gait problems commonly seen in Parkinson's patients. Choice B, "Impaired Role Performance," does not directly address the physical limitations caused by the disease. Choice C, "Ineffective Role Performance," focuses more on the client's inability to fulfill societal roles rather than the physical aspect of gait issues. Choice D, "Powerlessness," does not capture the primary concern of impaired movement and mobility in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Epinephrine. It is the first-line treatment for anaphylaxis as it rapidly reverses severe allergic reactions by constricting blood vessels, relaxing airway muscles, and increasing heart rate. Diphenhydramine (B) and steroids (C) are used as adjunct therapies but do not provide immediate relief like epinephrine. Albuterol (D) is used for bronchospasm in asthma, not for anaphylaxis. In summary, epinephrine is the most effective and life-saving medication for treating anaphylaxis.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the priority intervention to address severe shortness of breath, ensuring the client receives adequate oxygenation. Administering oxygen helps improve oxygen saturation levels and supports respiratory function. Encouraging deep breathing (B) may exacerbate the client's distress. Elevating the head of the bed (C) can help improve breathing but does not address the immediate need for oxygen. Administering antibiotics (D) is not indicated for shortness of breath unless there is an underlying infection causing it.