Which injury is the highest priority for a client entering the Emergency Department?

Correct Answer: C

Rationale: The correct answer is C, stab wound to the chest. This injury is the highest priority because it poses the greatest risk to the client's life due to potential damage to vital organs and major blood vessels. Immediate intervention is crucial to prevent severe bleeding, pneumothorax, or cardiac tamponade. Treating this injury promptly can significantly increase the client's chances of survival. The other choices are incorrect because: A: An open leg fracture, while serious, does not typically pose an immediate life-threatening risk compared to a stab wound to the chest. B: An open head injury can be severe, but not all head injuries are immediately life-threatening. D: Traumatic amputation of a thumb, while traumatic and painful, is not a priority compared to injuries that directly threaten a client's life.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and encourages the woman to share her coping mechanisms. This response acknowledges the woman's experience and allows her to express her feelings. It also opens up a dialogue for the nurse to assess her current coping strategies. Choice A is too general and does not prompt further discussion. Choice B is judgmental and dismissive of the woman's experiences. Choice D disregards the woman's emotional state and fails to address her current needs. Overall, Choice C is the most appropriate as it shows empathy, encourages open communication, and allows for further exploration of the woman's coping methods.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Correct Answer: A

Rationale: The correct answer is A because broccoli, oranges, and dark greens are rich in essential nutrients like vitamin C, antioxidants, and phytochemicals that boost the immune system and help prevent diseases. Broccoli contains sulforaphane, which has been shown to have anti-cancer properties. Oranges are high in vitamin C, crucial for immune function. Dark greens like spinach and kale are packed with vitamins and minerals that support overall health. Choice B is incorrect because no single food can cure many diseases. Choice C is incorrect because relying solely on vitamin pills may not provide all the necessary nutrients and benefits of whole foods. Choice D is incorrect as there is no scientific evidence supporting the concept of balancing body molecules through food.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps to reverse the symptoms quickly and prevent further complications. Administering corticosteroids (B) may be considered later for long-term management, but epinephrine is the immediate priority. Administering oxygen (C) may help with respiratory distress but does not address the underlying allergic reaction. Applying a cold compress (D) may provide temporary relief for local reactions but is not effective for a severe systemic allergic reaction.

Correct Answer: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: A

Rationale: The correct answer is A: objective. Objective data refers to measurable and observable information obtained through physical examination or diagnostic tests. In this case, the nurse's documentation of the patient's respirations and pulse rate are objective data as they can be quantified and verified by any healthcare professional. This data is not influenced by personal feelings or interpretations, making it objective. Choice B, reflective, is incorrect as it does not describe the nature of the data provided. Choice C, subjective, is also incorrect because subjective data is based on the patient's feelings or perceptions, which is not the case here. Choice D, introspective, is incorrect as it refers to internal self-reflection, not the nature of the data being documented.