Which nursing measure is most appropriate to meet the expected outcome of positive body image in a client with Kawasaki disease?

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

Correct Answer: C

Rationale: The correct answer is C: Check for dehydration. When a client has a high fever, assessing for dehydration is crucial because fever can lead to increased fluid loss through sweating and increased respiratory rate. Dehydration can exacerbate the client's condition and needs to be addressed promptly. Monitoring respiratory rate (choice A) and pulse (choice D) are important assessments but do not address the immediate need to identify dehydration. Obtaining a blood sample (choice B) may be necessary at some point but is not the initial priority in a client with a high fever. Thus, checking for dehydration should be assessed first to ensure proper management of the client's condition.

Correct Answer: A

Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.

Correct Answer: B

Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Limiting alcohol intake reduces blood pressure. Reducing sodium intake also helps manage hypertension. Alcohol can increase blood pressure, while sodium can lead to fluid retention. The patient's statement shows understanding of the importance of both factors in managing hypertension. Other Choices: A: Increasing sodium intake worsens fluid retention and hypertension. C: Processed foods are often high in sodium and unhealthy fats, worsening hypertension. D: Reducing exercise can lead to weight gain and increased blood pressure, contrary to managing hypertension.

Correct Answer: B

Rationale: The correct answer is B: Use a bath blanket for warmth and privacy. This is important when making an occupied bed to ensure the comfort and dignity of the patient. The bath blanket provides warmth and privacy during the bed-making process, maintaining the patient's comfort and respecting their privacy. Keeping the bed in a low position (choice A) is important for safety but not directly related to the patient's comfort during bed-making. Constantly raising side rails (choice C) is unnecessary and may cause discomfort to the patient. Moving back and forth between sides (choice D) is not essential for making an occupied bed and may disrupt the process.

Correct Answer: D

Rationale: The correct answer is D: discuss how the patient's food choices may affect her health and that of her baby. This is the most appropriate response because it addresses the potential impact of the patient's current diet on her health and the health of her baby during pregnancy. By discussing the implications of her food choices, the nurse can educate the patient on the importance of a balanced and nutritious diet for a healthy pregnancy. This approach promotes awareness and empowers the patient to make informed decisions for her and her baby's well-being. Incorrect choices: A: This option does not provide guidance or education on improving the patient's diet, which is crucial for a healthy pregnancy. B: Focusing on weight gain rather than nutritional content may not address the underlying issue of poor dietary choices. C: Assuming the patient's ability to cook or go grocery shopping may not address the immediate need for dietary education and guidance.

Correct Answer: D

Rationale: The correct answer is D because spirituality involves seeking meaning in one's life, which can provide a sense of purpose and fulfillment. This search is personal and introspective, focusing on individual values and beliefs. A, B, and C are incorrect because spirituality is not solely about belief in a supreme being, adherence to a specific system of beliefs, or the pursuit of life after death. Rather, it is about finding meaning, connection, and inner peace in one's existence.

Correct Answer: D

Rationale: The correct answer is D: All of the above. This is the best choice because reducing the risk of another stroke requires a holistic approach. A: Limiting sodium and cholesterol intake helps manage blood pressure and cholesterol levels, reducing the risk of stroke. B: Increasing physical activity and managing weight can improve cardiovascular health and overall well-being, reducing the risk of stroke. C: Taking prescribed medications regularly, such as blood thinners or antihypertensives, is crucial in preventing another stroke. In summary, all three choices address key risk factors for stroke prevention, making them essential components of a comprehensive stroke prevention plan.