Which physical finding indicates developmental dysplasia of the hip in an 11-12-month-old child?

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: D

Rationale: The correct answer is D because an episodic history is most appropriate for acute, short-term conditions like cold and flu symptoms seen in an outpatient clinic. This type of history focuses on the current problem and recent events leading up to it. Choice A involves a long-term care facility, which would require a more comprehensive history. Choice B describes a sudden severe symptom, which would prompt an urgent or emergent history. Choice C involves an upcoming surgical procedure, which would require a preoperative history. Therefore, option D is the most appropriate for an episodic history as it aligns with the acute nature of the condition and the focus on the current issue.

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

Correct Answer: A

Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.

Correct Answer: C

Rationale: The correct answer is C. Drinking caffeinated beverages can potentially increase blood pressure due to their stimulant effect. Limiting caffeine intake is recommended for patients with hypertension. Statement A is correct as reducing sodium and increasing potassium intake can help lower blood pressure. Statement B is correct as processed foods and fast food are typically high in sodium and unhealthy fats, which can worsen hypertension. Statement D is correct as fruits, vegetables, and whole grains are part of a heart-healthy diet for managing hypertension.

Correct Answer: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: A

Rationale: The correct answer is A: Apply a traction splint. The priority for a client with a fractured femur is to immobilize the fracture to prevent further injury and reduce pain. Applying a traction splint helps stabilize the fracture and reduce risk of complications such as nerve or blood vessel damage. Administering pain medication (B) is important but not the priority. Placing the client in a supine position (C) may be needed for comfort but does not address the primary concern of stabilizing the fracture. Administering IV antibiotics (D) is not necessary for a fractured femur unless there are signs of infection.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help dilate the airways, relieving bronchospasm and improving airflow in clients experiencing shortness of breath and wheezing. This intervention directly addresses the underlying cause of the symptoms. Administering corticosteroids (B) may be considered in severe cases to reduce inflammation but is not the priority initial intervention. Administering pain relief (C) is not indicated unless pain is identified as a contributing factor. Placing the client in a sitting position (D) can help improve breathing but does not directly address the bronchoconstriction causing the wheezing.