What is the primary intervention for a client with an acute myocardial infarction?

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. At 11-12 months, a child should be able to pull themselves to a standing position. Inability to do so suggests possible hip joint instability, a key risk factor for developmental dysplasia of the hip. Refusal to walk (A) is not specific to hip dysplasia. Negative Trendelenburg sign (C) indicates good hip abductor strength, which is not a risk factor. Negative Ortolani sign (D) is a maneuver used for hip joint assessment in infants and is not indicative of hip dysplasia risk at this age.

Correct Answer: A

Rationale: The correct answer is A because the dull sound over the ribs is a normal finding due to the presence of underlying solid structures such as the liver or spleen. Repositioning the hands or using more force is unnecessary as it won't change the nature of the sound. Referring the patient for additional investigation (choice D) is not warranted as this finding is commonly expected during percussion over the ribs.

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.

Correct Answer: B

Rationale: Correct Answer: B (Administer nonsteroidal anti-inflammatory drugs - NSAIDs) Rationale: 1. NSAIDs are commonly used for chronic pain management due to their anti-inflammatory properties. 2. NSAIDs target the underlying inflammation that often contributes to chronic pain. 3. Opioids may be reserved for severe pain due to their potential for addiction and side effects. 4. Monitoring blood pressure is important but not the primary intervention for chronic pain. 5. Acetaminophen is a mild pain reliever and may not be as effective for chronic pain compared to NSAIDs.

Correct Answer: B

Rationale: The correct answer is B: Pernicious anemia. This condition is characterized by a deficiency in vitamin B12, leading to neurological symptoms like tingling sensations in the feet (peripheral neuropathy) and glossitis, causing the tongue to become red and painful. Polycythemia (A) is an increase in red blood cell mass, not related to the symptoms described. Micronucleus anemia (C) is not a recognized medical condition. Iron-deficiency anemia (D) can lead to symptoms like fatigue and pallor, but not typically tingling sensations in the feet or glossitis.

Correct Answer: C

Rationale: The correct answer is C: Critical thinking. Critical thinking involves analyzing information, evaluating options, and making sound decisions. When caring for multiple clients with complex care, critical thinking enables nurses to prioritize tasks, anticipate complications, and adapt care plans accordingly. Diagnostic reasoning (A) is important but focuses on identifying specific health issues. Physical assessment (B) is crucial but only addresses one aspect of care. Nursing care plans (D) are essential tools but rely on critical thinking for effective implementation. In conclusion, critical thinking is the key as it encompasses all aspects of problem-solving in complex care situations.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are crucial in treating DVT as they prevent blood clots from getting larger and stop new clots from forming. They help reduce the risk of complications like pulmonary embolism. Administering analgesics (B) may help with pain but does not address the root cause. Diuretics (C) are used to treat conditions like fluid retention, not DVT. Applying a warm compress (D) can actually worsen DVT by promoting blood flow. Anticoagulants are the gold standard treatment for DVT.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Washing hands before and after cord care is a standard hygiene practice to prevent infection. 2. Options A and B are incorrect as alcohol and covering the cord can lead to complications. 3. Option C suggests recognizing concerning changes in the cord, indicating good understanding. 4. Thus, option D is correct as it is a crucial step in cord care and does not indicate a need for further teaching.