Which is the MOST appropriate intervention should the nurse do to help family perform the health tasks?

Correct Answer: B

Rationale: Helping the family recognize the problem is the most appropriate intervention to assist them in performing health tasks. By recognizing the problem, the family can better understand the need for action and be motivated to take steps to address it. This intervention enables the family to become more engaged in their healthcare decision-making process and enhances their ability to effectively manage their health tasks. It empowers them to seek appropriate health resources and make informed choices in promoting their health and well-being. Ultimately, by acknowledging the problem, the family is better equipped to initiate positive changes and improve their overall health outcomes.

Correct Answer: B

Rationale: The past medical history section typically includes information about a person's medical background before the current point in time. This would involve details such as prenatal history, birth history, childhood illnesses, surgeries, and medical conditions that have occurred in the past. "Current history" would be more appropriate for the present medical status and ongoing health issues, hence it does not belong in the past medical history section.

Correct Answer: A

Rationale: X-ray is the most appropriate imaging modality for evaluating wrist involvement in rheumatoid arthritis. It can show joint space narrowing, erosions, soft tissue swelling, and periarticular osteopenia. X-rays are readily available, cost-effective, and provide valuable information about joint damage and disease progression in rheumatoid arthritis. In this case, X-ray would be able to confirm the presence of erosions, joint deformities, and assess the severity of the disease in the wrist joint. While MRI and ultrasound can also be helpful in evaluating rheumatoid arthritis, X-ray remains the initial imaging modality of choice due to its convenience and ability to assess bony changes. Dual-energy X-ray absorptiometry (DEXA) scan is not indicated for evaluating wrist involvement in rheumatoid arthritis.

Correct Answer: A

Rationale: The presentation described in the question is characteristic of anterior uveitis. Anterior uveitis is inflammation of the iris and ciliary body in the eye. Patients typically present with symptoms such as redness, pain, and photophobia. Slit-lamp examination findings include ciliary injection (redness and engorgement of blood vessels in the ciliary body), corneal edema (swelling of the cornea), and a mid-dilated pupil with a fixed reaction to light due to involvement of the iris muscles. These features differentiate anterior uveitis from other conditions. Treatment of anterior uveitis may involve topical steroids and cycloplegics to reduce inflammation and alleviate symptoms.

Correct Answer: C

Rationale: It is crucial to ensure that the autoclave is functioning properly to achieve proper sterilization of surgical instruments. If the autoclave is not reaching the required temperature, it signifies a technical issue that needs to be addressed promptly. The nurse should notify the sterile processing department immediately and request maintenance to investigate and resolve the problem. Continuing with sterilization without addressing the temperature issue can compromise the effectiveness of sterilization and pose a risk of infection to patients. Adjusting the settings on the autoclave or using an alternative method of sterilization are not appropriate actions in this situation.

Correct Answer: B

Rationale: Possessing a body of knowledge is an important element that characterizes nursing as a profession. Nursing is a field that requires specialized education, training, and expertise in various areas of healthcare. Nurses are expected to have a comprehensive understanding of anatomy, physiology, pharmacology, and various nursing theories and practices to effectively care for patients. This body of knowledge distinguishes nursing as a profession and supports the delivery of high-quality, evidence-based patient care. While the other options (having members, being service-oriented, and a calling) are also important aspects of nursing, possessing a body of knowledge is fundamental to the profession's identity and practice.

Correct Answer: C

Rationale: In this scenario, the action that violates a psychiatric patient's rights is option C, where staff members confiscated written letters done by patients addressed to the local newspaper. Patients have the right to communicate freely and express their thoughts and feelings through various means, such as letter-writing. Confiscating these letters is a violation of their rights to free expression and communication. It is essential to respect and uphold the rights of psychiatric patients, including their right to communicate with others.

Correct Answer: D

Rationale: Consistent limit setting is an effective nursing intervention for managing impulsive and aggressive behaviors in individuals with conduct disorder. By establishing clear and consistent boundaries, rules, and consequences, individuals with conduct disorder can learn self-control and appropriate behavior. Consistent limit setting provides structure and predictability, helping to reduce impulsive and aggressive reactions in these individuals. It also teaches them accountability for their actions and reinforces appropriate behavior. Additionally, setting limits helps to establish a sense of safety and security for both the individual and those around them. Therefore, consistent limit setting is a crucial intervention to help manage impulsive and aggressive behaviors associated with conduct disorder.

Correct Answer: B

Rationale: The most appropriate intervention for a patient with difficulty swallowing due to end-stage ALS and concerns about choking is to refer the patient to a speech therapist for swallowing exercises and techniques (Choice B). Speech therapists are trained to assess and manage swallowing difficulties in patients, especially those with neurodegenerative diseases like ALS. They can provide specific exercises and strategies to help the patient swallow safely and reduce the risk of choking. This intervention focuses on addressing the underlying issue causing the difficulty swallowing and aims to improve the patient's quality of life by enhancing their ability to eat and drink. The other options are not as effective or appropriate in addressing the patient's concerns.