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: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

Correct Answer: B

Rationale: The correct answer is B: To monitor the amount of airway obstruction. A peak flow meter is used to measure how well the patient can exhale air from the lungs, indicating the degree of airway obstruction in conditions like asthma. By monitoring peak flow readings, the nurse can assess the severity of the patient's asthma and adjust treatment accordingly. Choices A, C, and D are incorrect: A: To measure the amount of oxygen in the blood - This is the function of a pulse oximeter, not a peak flow meter. C: To measure the frequency of inhaler use - This is not the primary purpose of a peak flow meter, which is specifically used to monitor airway obstruction. D: To track blood glucose levels - This is the function of a glucometer, not a peak flow meter used for asthma management.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In ARDS, the primary issue is hypoxemia due to impaired gas exchange in the lungs. Administering oxygen helps to increase the oxygen levels in the blood, improving oxygenation to vital organs. Corticosteroids (B) are not indicated as they have not shown consistent benefit in ARDS treatment. Bronchodilators (C) are not effective as ARDS is not primarily a bronchoconstrictive disorder. Applying an ice pack to the chest (D) is not relevant and will not address the underlying hypoxemia. Administering oxygen is the most effective and essential intervention to correct hypoxemia in ARDS.

Correct Answer: D

Rationale: The correct answer is D: Colace. When a client is immobilized and experiencing constipation, a stool softener like Colace is appropriate to prevent straining and discomfort. Advil and Anasaid are pain relievers, not laxatives. Clinocil is not a recognized medication. Colace is the best choice to address constipation in this scenario.

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: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.

Correct Answer: B

Rationale: The correct answer is B because a functional health assessment evaluates various health patterns such as roles, relationships, coping mechanisms, stress tolerance, and lifestyle choices, providing a holistic view of the individual's well-being. Vital signs and circulation (A) are typically included in a physical assessment, not a functional health assessment. Assessing specific organ abnormalities (C) would be part of a focused physical examination or diagnostic testing. Acute symptoms (D) are important to address but do not encompass the comprehensive evaluation of health patterns that a functional health assessment covers.

Correct Answer: A

Rationale: The correct answer is A because as a nurse, it is essential to respect and accommodate the cultural beliefs and preferences of patients. By offering to assist in arranging for the presence of the medicine woman, the nurse shows empathy, cultural competence, and patient-centered care. This approach promotes trust, communication, and collaboration with the patient. Choice B is incorrect as it disregards the patient's request and shows a lack of respect for their beliefs. Choice C is incorrect as it dismisses the significance of the patient's request, which can impact the therapeutic relationship. Choice D is incorrect as it invalidates the patient's beliefs and cultural practices, which can lead to feelings of disrespect and lack of trust.