What should a nurse do if they observe a client sitting alone and talking to the voices?

Correct Answer: A

Rationale: The correct answer is A because asking the client to describe the voices can help the nurse assess the situation and understand the client's experience better. This can provide valuable information for the nurse to determine the appropriate intervention or treatment. Leaving the client alone (B) may not address the underlying issue and could potentially worsen the situation. Encouraging the client to talk about the voices (C) is helpful, but asking for a description first allows for a more systematic assessment. Telling the client there are no voices (D) is dismissive and denies the client's reality, which can be harmful and ineffective in providing appropriate care.

Correct Answer: A

Rationale: Step-by-step rationale: 1. High HDL cholesterol is considered beneficial as it helps remove LDL cholesterol from arteries, reducing the risk of plaque buildup. 2. Low HDL cholesterol is associated with an increased risk of cardiovascular disease. 3. Low total cholesterol may not necessarily indicate a decreased risk, as it could be due to low levels of protective HDL cholesterol. 4. Low triglycerides, while generally considered good, do not directly indicate a decreased risk of cardiovascular disease like high HDL cholesterol does. In summary, high HDL cholesterol is the correct answer as it plays a crucial role in reducing the risk of cardiovascular disease by removing LDL cholesterol, whereas the other choices do not offer the same protective benefits.

Correct Answer: B

Rationale: The correct answer is B: Administer fluids. Administering fluids is the priority when caring for a client receiving a blood transfusion to prevent circulatory overload. Vital signs (A) should be monitored before and after the transfusion but are not the priority. Monitoring for transfusion reactions (C) is important but comes after administering fluids. Obtaining a blood sample (D) is not a priority during a blood transfusion. Administering fluids ensures adequate hydration and prevents complications during the transfusion process.

Correct Answer: C

Rationale: The primary purpose of an abdominal binder after surgery is to increase circulation. An abdominal binder helps improve blood flow to the surgical site, which can aid in reducing swelling, promoting healing, and preventing complications such as blood clots. It provides gentle compression to support the abdominal muscles and tissues without restricting circulation. Choice A (Promote comfort) is incorrect because while an abdominal binder may provide some comfort by supporting the abdomen, its primary purpose is not solely for comfort. Choice B (Prevent infection) is incorrect because an abdominal binder does not directly prevent infection. Infection prevention is primarily achieved through proper wound care and infection control practices. Choice D (Provide wound care) is incorrect because an abdominal binder does not provide wound care. Wound care involves cleaning, dressing changes, and monitoring for signs of infection, which are separate from the purpose of an abdominal binder.

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.