What term describes excessive stretching of a ligament, as seen in a client with a pulled ligament?

Correct Answer: B

Rationale: The correct answer is B: strain. A strain refers to excessive stretching or tearing of a muscle or tendon, not a ligament. A sprain (choice A) is the correct term for excessive stretching of a ligament. Subluxation (choice C) refers to partial dislocation of a joint, not a ligament injury. Distortion (choice D) is a general term that does not specifically describe ligament stretching. Therefore, the correct term for excessive stretching of a ligament is a sprain, making choice A the correct answer.

Correct Answer: C

Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function. A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism. B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism. D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.

Correct Answer: A

Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.

Correct Answer: D

Rationale: The correct answer is D because clients with renal disease may have impaired kidney function, leading to difficulty in regulating potassium levels. High potassium intake can further burden the kidneys, potentially causing hyperkalemia. Clients on diuretic therapy (choice A) may actually need to monitor potassium levels due to potential electrolyte imbalances. Clients with an ileostomy (choice B) typically do not have issues with potassium absorption. Clients with metabolic alkalosis (choice C) may have potassium shifts but do not necessarily need to avoid high-potassium foods unless specifically advised by their healthcare provider.

Correct Answer: A

Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.

Correct Answer: B

Rationale: The correct answer is B because increasing physical activity and reducing stress are important lifestyle changes for managing chronic hypertension. Exercise helps lower blood pressure and stress reduction techniques can help control hypertension. Option A is incorrect as reducing sodium intake, not increasing it, is recommended. Option C is incorrect as medications for hypertension should be taken as prescribed, not only when blood pressure increases. Option D is incorrect as monitoring blood pressure should be done regularly, but not necessarily every week.

Correct Answer: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, the priority is to maintain adequate hydration to support kidney function. IV fluids help improve renal perfusion and urine output. Monitoring vital signs is important but not the priority. Performing a kidney function test can provide valuable information but does not address the immediate need for fluid resuscitation. Administering IV antibiotics may be necessary if there is an infection contributing to renal failure, but hydration takes precedence. In summary, administering IV fluids is crucial to support kidney function in acute renal failure, making it the top priority among the choices given.

Correct Answer: A

Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.