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: A

Rationale: The correct answer is A: Fever. Fever is an early indicator of infection as it is the body's natural response to fighting off pathogens. When the body detects an infection, it raises its temperature to create an inhospitable environment for the pathogens. Pain at the surgical site (B) is common post-operatively but may not necessarily indicate infection. Redness at the incision site (C) can be a sign of inflammation but is not specific to infection. Increased heart rate (D) can occur due to various reasons post-operatively, not just infection. Fever is a systemic response and a more reliable early indicator of infection in this context.

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: Administer antibiotics. When caring for a client with severe burns, the first priority is to prevent infection, which can be life-threatening. Administering antibiotics helps reduce the risk of infection. Cleansing and dressing the wounds can come after ensuring infection control. Performing a tracheostomy is not typically the first priority unless there are airway concerns. Administering analgesics is important, but it is not the first priority in this case.

Correct Answer: A

Rationale: The correct answer is A: Chest pain. A symptom is a subjective indication of a condition experienced by the patient. Chest pain is a subjective sensation that a patient reports, making it a symptom. Clammy skin, serum potassium level, and temperature are all objective signs or measurements, not subjective experiences reported by the patient. Symptoms are what the patient feels or experiences, while signs are objective findings that can be measured or observed by healthcare providers.

Correct Answer: D

Rationale: The correct answer is D because all choices (A, B, and C) can increase the risk of STDs. Alcohol use can impair judgment leading to risky sexual behavior. Certain sexual practices (such as unprotected sex or having multiple partners) can directly increase the risk of STD transmission. Oral contraception does not protect against STDs, so individuals relying solely on it may still be at risk. Therefore, all of the above factors can contribute to an increased risk of contracting STDs.

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.

Correct Answer: C

Rationale: The correct answer is C because it reflects empathy by acknowledging the mother's feelings without judgment or personal bias. The nurse shows understanding and compassion by recognizing the difficulty of the situation. Incorrect answer A lacks empathy as it simply restates the mother's feeling without demonstrating understanding. Answer B also lacks empathy as it focuses on the boyfriend's actions rather than the mother's feelings. Answer D shows some empathy by acknowledging the difficulty but fails to address the mother's emotional state directly. In summary, answer C is correct because it shows empathy by acknowledging the mother's emotions and validating her experience without judgment or redirection.

Correct Answer: B

Rationale: The correct answer is B. When a patient with severe injuries is brought to the emergency department, the nurse should prioritize performing a physical examination and initiating lifesaving measures while asking history questions simultaneously. This approach allows for immediate assessment and intervention to address any life-threatening conditions. Gathering history information while performing the examination ensures that critical details are not missed and helps in making timely decisions. Choosing option A could delay lifesaving interventions, while option C is not a priority during the initial assessment of a critically injured patient. Option D is incorrect as it prioritizes lifesaving measures over obtaining important history information during the initial assessment.