What type of assessment focuses on roles and relationships of the client?

Correct Answer: C

Rationale: The correct answer is C: Functional. Functional assessment focuses on roles and relationships of the client by evaluating how well they can perform daily activities and interact with others. This type of assessment provides valuable insights into a client's overall well-being and ability to function independently. Incorrect choices: A: Body systems - This type of assessment focuses on the physical structures and functions of the body, not on the client's roles and relationships. B: Head to toe - This refers to a comprehensive physical examination from head to toe, which does not specifically address the client's roles and relationships. D: Focused - This type of assessment targets a specific issue or concern, but it may not necessarily delve into the client's roles and relationships.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Correct Answer: B

Rationale: The correct answer is B: secondary prevention. Teaching a client with gonorrhea about reinfection prevention falls under secondary prevention, which aims to detect and treat a disease early to prevent complications and further transmission. This intervention occurs after the client has already been diagnosed with gonorrhea, focusing on preventing reinfection and spreading the infection to others. A: Primary prevention focuses on preventing the disease from occurring in the first place, such as promoting safe sex practices to prevent gonorrhea infection. C: Tertiary prevention involves managing and preventing complications of a disease that has already occurred, which is not the case with teaching about reinfection prevention. D: Primary health care prevention is a broad term that encompasses various aspects of healthcare delivery, but it does not specifically address the prevention of reinfection in a client with gonorrhea.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are crucial in treating DVT as they prevent blood clots from getting larger and stop new clots from forming. They help reduce the risk of complications like pulmonary embolism. Administering analgesics (B) may help with pain but does not address the root cause. Diuretics (C) are used to treat conditions like fluid retention, not DVT. Applying a warm compress (D) can actually worsen DVT by promoting blood flow. Anticoagulants are the gold standard treatment for DVT.

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: D

Rationale: The correct answer is D: provide culturally sensitive and appropriate care. Including cultural information in the health assessment helps healthcare providers understand the patient's beliefs, practices, and preferences, allowing for tailored care that respects the patient's cultural background. This improves communication, trust, and overall health outcomes. Choice A is incorrect because cultural information does not necessarily identify the cause of an illness. Choice B is incorrect as it overemphasizes diagnosis without considering the patient's cultural context. Choice C is incorrect as it does not directly address the importance of cultural information in healthcare.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. In chronic heart failure, the heart cannot pump blood effectively, leading to fluid buildup in the lungs causing pulmonary edema. Monitoring for signs such as shortness of breath, wheezing, and crackles can help prevent respiratory distress. Incorrect choices: A: Hypoglycemia - Not directly related to chronic heart failure. B: Hyperkalemia - Can occur in heart failure but not a primary complication to monitor for. D: Anemia - Can be a consequence of chronic heart failure but not a primary complication to monitor for.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The priority nursing action for a client with severe dehydration is to restore fluid volume to maintain vital organ function. Administering IV fluids is crucial in rapidly replenishing lost fluids and electrolytes. Corticosteroids (choice B) are not indicated for dehydration. Re-administering IV fluids (choice C) is redundant. Administering analgesics (choice D) is not a priority in the management of severe dehydration.