What is the most effective way to manage a client with deep vein thrombosis (DVT)?

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: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and encourages the woman to share her coping mechanisms. This response acknowledges the woman's experience and allows her to express her feelings. It also opens up a dialogue for the nurse to assess her current coping strategies. Choice A is too general and does not prompt further discussion. Choice B is judgmental and dismissive of the woman's experiences. Choice D disregards the woman's emotional state and fails to address her current needs. Overall, Choice C is the most appropriate as it shows empathy, encourages open communication, and allows for further exploration of the woman's coping methods.

Correct Answer: D

Rationale: The correct answer is D because it directly asks for specific information about past hospitalizations, prompting Mr. Y to recall the last time he was admitted for chest pain. This question is open-ended, allowing Mr. Y to provide detailed information voluntarily. A is incorrect as it assumes Mr. Y has been hospitalized without directly asking for that information. B is a better choice but lacks specificity in requesting details about past hospitalizations. C is inappropriate as it assumes permission to access medical records without Mr. Y's consent.

Correct Answer: A

Rationale: The correct first action for a nurse when caring for a client with acute shortness of breath is to administer oxygen (Choice A). Oxygen is essential to support the client's respiratory function and improve oxygenation. Administering corticosteroids (Choice B) may be considered later for certain underlying conditions, but oxygen takes precedence. Administering pain relief (Choice C) is not the priority in this situation. Placing the client in a supine position (Choice D) can potentially worsen respiratory distress in some cases, making it an incorrect choice.

Correct Answer: B

Rationale: The correct answer is B: "Are you able to dress yourself?" This question is the most important because it directly assesses the patient's functional abilities post-stroke, providing crucial information about their independence and self-care abilities. It helps determine the patient's level of disability and need for assistance with activities of daily living. Choice A: "Do you wear glasses?" is not as important in this context as it does not directly address the patient's functional status post-stroke. Choice C: "Do you have any thyroid problems?" is irrelevant to the functional assessment of a patient post-stroke. Choice D: "How many times a day do you have a bowel movement?" is not as critical as assessing the patient's ability to perform basic activities of daily living.

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing exercises. For a client with a history of asthma and wheezing, deep breathing exercises help improve lung function and reduce the frequency of asthma attacks. These exercises can strengthen respiratory muscles, increase lung capacity, and enhance overall breathing efficiency. Administering bronchodilators (choice A) may provide immediate relief but does not address long-term management. Administering oxygen and encouraging fluid intake (choice B) may be helpful in certain situations but does not specifically target asthma symptoms. Administering corticosteroids (choice C) is typically used for severe asthma exacerbations and should not be the first-line treatment for someone with a history of asthma and wheezing.

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.

Correct Answer: A

Rationale: The correct answer is A: Administer thrombolytics. Thrombolytics help dissolve blood clots causing the stroke, restoring blood flow to the brain. This intervention is time-sensitive to prevent further brain damage. Administering aspirin (B) is important but not the priority over thrombolytics. Performing an ECG (C) assesses heart function, not the immediate intervention for stroke. Administering corticosteroids (D) is not indicated in acute stroke management.