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: A

Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.

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: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

Correct Answer: C

Rationale: The correct answer is C. The nurse should prevent infiltration of calcium to avoid tissue necrosis and sloughing. Infiltration of calcium can lead to severe tissue damage due to its caustic nature. Therefore, the nurse should be vigilant in monitoring the IV site and ensuring proper placement to prevent this complication. Choice A is incorrect because infusing hypertonic solutions rapidly can lead to fluid overload and electrolyte imbalances. Choice B is incorrect because exceeding the recommended amount of potassium per liter of fluid can result in hyperkalemia, which can be dangerous. Choice D is incorrect because calcium does not diminish digitalis's action; in fact, calcium can potentiate the effects of digitalis.

Correct Answer: D

Rationale: The correct answer is D because an episodic history is most appropriate for acute, short-term conditions like cold and flu symptoms seen in an outpatient clinic. This type of history focuses on the current problem and recent events leading up to it. Choice A involves a long-term care facility, which would require a more comprehensive history. Choice B describes a sudden severe symptom, which would prompt an urgent or emergent history. Choice C involves an upcoming surgical procedure, which would require a preoperative history. Therefore, option D is the most appropriate for an episodic history as it aligns with the acute nature of the condition and the focus on the current issue.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Correct Answer: B

Rationale: Mammography is used to detect tumors in the breast tissue by taking X-ray images. Tumors can be cancerous or benign, making early detection crucial for treatment. Pain (A) is a symptom, not detected by mammography. Edema (C) is swelling caused by fluid retention, not a primary target of mammography. Epilepsy (D) is a neurological disorder, unrelated to mammography's purpose. Therefore, the correct answer is B.