When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

Correct Answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

Correct Answer: B

Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.

Correct Answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or health care provider if any questions arise. Direct communication with healthcare professionals involved in the client's care is crucial to address any concerns promptly and accurately, ensuring the client's safety and understanding of the prescribed medication.

Correct Answer: A

Rationale: The correct answer is A) Document that the client responds to a painful stimulus. In the context of using the Glasgow Coma Scale (GCS) for a neurologic assessment, the client's response of wincing and pulling away from a painful stimulus indicates a motor response to pain. This is a crucial piece of information to document accurately in the client's medical record as it provides valuable insight into the client's level of consciousness and neurologic function. Option B) Observe the client's response to verbal stimulation is incorrect because the scenario specifically describes a response to a painful stimulus, not verbal stimulation. While assessing the client's response to verbal stimuli is important in a neurologic assessment, in this case, the focus is on the response to a painful stimulus. Option C) Place the client on seizure precautions for 24 hours is incorrect as there is no indication in the scenario that the client is at risk for seizures based on the provided information. Placing a client on seizure precautions without a valid reason can lead to unnecessary interventions and potential adverse effects. Option D) Report decorticate posturing to the healthcare provider is incorrect because the client's response of wincing and pulling away from a painful stimulus does not indicate decorticate posturing. Decorticate posturing involves specific abnormal posturing of the arms and legs that is indicative of severe brain injury, which is not described in the scenario. In an educational context, understanding the correct assessment and documentation of neurologic responses, such as those measured by the GCS, is crucial for healthcare professionals, especially in critical care settings. Accurate and timely assessment allows for appropriate interventions and monitoring of clients with neurologic alterations, improving patient outcomes and safety.

Correct Answer: C

Rationale: The nurse should inform the surgeon immediately that the operative permit is not signed and that the client has questions about the surgery. It is crucial for the surgeon to be aware of the situation so they can address the client's concerns, explain the procedure, and obtain the necessary signed permit before proceeding with the surgery. This ensures informed consent and compliance with preoperative protocols.