When using the mnemonic PQRSTU to help remember all the points of a patient's perception of his or her problem, what does the "S" signify?

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

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: Cleanse and dress the wound. This intervention is essential as it helps prevent infection, promotes healing, and maintains a moist wound environment. Cleansing removes debris and bacteria, while dressing protects the wound from external contaminants. Administering antibiotics (choice B) is not the initial intervention for an open wound. Placing a sterile dressing (choice C) is important, but cleansing the wound first is crucial. Ensuring wound care is sterile (choice D) is important, but the primary focus should be on cleansing and dressing the wound.

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (D) is important but not the primary action in a hypertensive emergency.

Correct Answer: D

Rationale: The correct answer is D: Hold the breath for at least 5 seconds after inhaling the medication. Holding the breath after inhaling the medication allows for better absorption of the medication into the lungs. This helps ensure the medication reaches the target area for optimal effectiveness. Exhaling deeply before using the inhaler (Choice A) is not necessary and can actually reduce the amount of medication reaching the lungs. Using the inhaler only when asthma symptoms are severe (Choice B) is not recommended as it is important to use the inhaler as prescribed by the healthcare provider. Inhaling deeply while activating the inhaler (Choice C) is important, but holding the breath after inhaling the medication is crucial for optimal medication delivery.

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: B

Rationale: The correct answer is B: Body Image Disturbance. Infertility can impact one's perception of self and body image, leading to feelings of incompleteness. This nursing diagnosis addresses the emotional distress related to altered self-perception. A: Risk for Self Harm is not directly related to the client's statement about feeling incomplete due to infertility. C: Ineffective Role Performance doesn't specifically address the client's feelings of incompleteness related to infertility. D: Powerlessness may not fully capture the client's emotional struggle with their body image and feelings of incompleteness due to infertility.

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: 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.