What is the priority nursing intervention for a client experiencing chest pain and a history of heart disease?

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the priority intervention because nitroglycerin helps dilate blood vessels, reducing chest pain in clients with heart disease. It improves blood flow to the heart, relieving ischemia. Morphine (B) can mask symptoms and should be used if pain persists after nitroglycerin. Beta blockers (C) are beneficial in chronic management but not for immediate relief. Aspirin (D) helps prevent clot formation but is not the priority in acute chest pain.

Correct Answer: A

Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.

Correct Answer: A

Rationale: The correct answer is A - Administer IV fluids. This is the priority intervention for a client with suspected hypovolemia and hypotension as it helps to restore intravascular volume and improve blood pressure. IV fluids will address the underlying cause of hypotension by increasing circulating volume. Monitoring blood pressure (B) is important but administering IV fluids takes precedence. Administering corticosteroids (C) is not indicated for hypovolemia and hypotension. Administering oxygen (D) may be necessary if there is evidence of hypoxia, but addressing fluid volume status is the primary concern in this scenario.

Correct Answer: C

Rationale: The correct answer is C because monitoring kidney function with regular laboratory tests is crucial in managing CKD. Regular testing helps identify changes in kidney function early, allowing for timely interventions to prevent complications. Administering diuretics (choice A) may worsen kidney function. Encouraging weight loss (choice B) may be necessary, but monitoring kidney function takes precedence. Encouraging the patient to limit fluid intake (choice D) may be necessary in some cases, but it is not the priority intervention.

Correct Answer: B

Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.

Correct Answer: A

Rationale: The correct answer is A because using the defrost setting on microwave ovens can help safely heat breast milk or formula for the infant without compromising its quality. This method ensures that the milk is heated evenly and prevents hot spots that could burn the baby's mouth. Choice B is incorrect because refrigerating partially used bottles can lead to bacterial growth and contamination. Choice C is incorrect as mixing water and concentrate in different ratios can result in either too diluted or too concentrated formula, which can be harmful to the infant. Choice D is incorrect as adding new formula to partially used bottles can also lead to bacterial growth and spoilage.

Correct Answer: B

Rationale: The correct answer is B: dominant health care culture. The scenario illustrates the influence of the dominant health care culture, where the daughter, as a dental hygienist, is advocating for her mother to follow the plan of care based on her professional knowledge and beliefs. This highlights the power dynamics and authority within the healthcare system, where individuals with certain expertise may exert influence over others, even family members. This is distinct from generational differences (A) which focus on age-related disparities, lack of respect for independence (C) which emphasizes autonomy and decision-making, and critical cultural perspective (D) which involves a deeper analysis of cultural influences on healthcare interactions.

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (D) is important but not the primary action in a hypertensive emergency.

Correct Answer: C

Rationale: The correct answer is C, BMI indicates obesity (35). To calculate BMI, we use the formula BMI = (Weight in pounds / (Height in inches x Height in inches)) x 703. Plugging in the values (216 / (66 x 66)) x 703, we get a BMI of approximately 35. A BMI of 35 falls within the obesity category (BMI 30 or higher). Choice A is incorrect because a BMI of 35 is not within normal limits. Choice B is incorrect as a BMI of 27 would indicate overweight status, not obesity. Choice D is incorrect as the BMI calculated is higher than normal, not lower.