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: A

Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.

Correct Answer: B

Rationale: The correct answer is B because asking someone who knows the patient well can provide valuable insight into the meaning behind the verbal and nonverbal communication discrepancy. This helps in understanding the context and potential reasons for the inconsistency. Option A is incorrect as ignoring nonverbal behaviors can lead to missing important cues. Option C of interpreting messages as an 'average' may oversimplify the complexity of communication. Option D is incorrect as while nonverbal behaviors can provide valuable information, solely focusing on them may not give a complete understanding of the situation.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. This is the first step in the care of a client with a severe allergic reaction because epinephrine is the primary medication used to reverse the life-threatening symptoms of anaphylaxis. Epinephrine acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve breathing, and increase heart rate. Administering epinephrine promptly can prevent progression to severe outcomes like respiratory failure or shock. Corticosteroids (B and C) are used as adjunct therapy and do not provide immediate relief. Applying a cold compress (D) does not address the systemic effects of anaphylaxis and can delay potentially life-saving treatment.

Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.

Correct Answer: A

Rationale: The correct answer is A: Psoriasis. Psoriasis is characterized by red, scaly patches on the skin, which align with the symptoms described. Psoriasis commonly affects the lower legs and is associated with severe itching. Eczema (choice B) is characterized by red, inflamed, and itchy skin patches, but typically presents differently from psoriasis. Contact dermatitis (choice C) is a localized reaction that occurs when the skin comes into contact with an irritant or allergen, and fungal infections (choice D) typically present with itching, redness, and sometimes peeling skin, but not necessarily scaly patches like psoriasis.

Correct Answer: B

Rationale: The correct answer is B because conveying respect for differences helps build trust and encourages patients to share their perspectives openly. This fosters a positive patient-provider relationship and enhances communication. Choice A is incorrect as patients have unique behaviors. Choice C is incorrect as cultural expectations do not fully explain individual differences. Choice D is incorrect as expressing one's culture is not solely dependent on exposure to Canadian values.

Correct Answer: C

Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.

Correct Answer: B

Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.