What should the nurse monitor first for a client with a recent stroke?

Correct Answer: C

Rationale: The correct answer is C: Administer aspirin. Aspirin should be administered first to prevent further clot formation and reduce the risk of recurrent stroke. Monitoring blood pressure (A) is important but not the first priority. Administering IV fluids (B) is not necessary unless indicated. Applying a warm compress (D) is not a priority in the acute management of a stroke. Administering aspirin promptly can significantly impact the client's outcome by preventing further clot formation.

Correct Answer: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

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: B

Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.

Correct Answer: C

Rationale: The correct answer is C: Administer aspirin. Aspirin should be administered first to prevent further clot formation and reduce the risk of recurrent stroke. Monitoring blood pressure (A) is important but not the first priority. Administering IV fluids (B) is not necessary unless indicated. Applying a warm compress (D) is not a priority in the acute management of a stroke. Administering aspirin promptly can significantly impact the client's outcome by preventing further clot formation.

Correct Answer: A

Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.

Correct Answer: C

Rationale: The correct answer is C: Using biased or leading questions. This question is biased and leading because it assumes that the patients attending the workshop do not engage in smoking, drinking, or drug use. It may influence the patients to provide inaccurate information if they feel pressured to conform to societal expectations. In health assessments, it is important to ask open-ended, non-judgmental questions to gather accurate and comprehensive information. Incorrect choices: A: Talking too much - This choice is not relevant to the question as it does not address the issue of biased or leading questions. B: Using confrontation - This choice does not apply as the question does not involve confronting the patients. D: Using blunt language to deal with distasteful topics - While the question may be blunt, the main issue is the bias and leading nature of the question, not its bluntness.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.

Correct Answer: C

Rationale: The correct intervention for hyperkalemia is to administer insulin (Choice C). Insulin drives potassium into cells, lowering serum potassium levels. This is effective in acutely reducing high potassium levels. Administering calcium gluconate (Choice A) is used for stabilizing cardiac membranes in hyperkalemia but does not lower potassium levels. Sodium bicarbonate (Choice B) is used for metabolic acidosis, not hyperkalemia. Furosemide (Choice D) is a loop diuretic that can lead to potassium loss but is not the primary intervention for hyperkalemia.