Which statement by newborn parents does not indicate a need for further teaching about cord care?

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Washing hands before and after cord care is a standard hygiene practice to prevent infection. 2. Options A and B are incorrect as alcohol and covering the cord can lead to complications. 3. Option C suggests recognizing concerning changes in the cord, indicating good understanding. 4. Thus, option D is correct as it is a crucial step in cord care and does not indicate a need for further teaching.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. In chronic heart failure, the heart cannot pump blood effectively, leading to fluid buildup in the lungs causing pulmonary edema. Monitoring for signs such as shortness of breath, wheezing, and crackles can help prevent respiratory distress. Incorrect choices: A: Hypoglycemia - Not directly related to chronic heart failure. B: Hyperkalemia - Can occur in heart failure but not a primary complication to monitor for. D: Anemia - Can be a consequence of chronic heart failure but not a primary complication to monitor for.

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates cultural competence and respect for the patient's beliefs. It shows willingness to accommodate the patient's request, promoting trust and effective communication. Choice B is incorrect as it dismisses the patient's request and may lead to distrust. Choice C is incorrect as it disregards the patient's cultural beliefs and can be perceived as insensitive. Choice D is incorrect as it invalidates the patient's beliefs and can hinder the therapeutic relationship. Ultimately, choice A is the most appropriate response to promote patient-centered care and build a trusting relationship with the patient.

Correct Answer: A

Rationale: Step-by-step rationale: 1. High HDL cholesterol is considered beneficial as it helps remove LDL cholesterol from arteries, reducing the risk of plaque buildup. 2. Low HDL cholesterol is associated with an increased risk of cardiovascular disease. 3. Low total cholesterol may not necessarily indicate a decreased risk, as it could be due to low levels of protective HDL cholesterol. 4. Low triglycerides, while generally considered good, do not directly indicate a decreased risk of cardiovascular disease like high HDL cholesterol does. In summary, high HDL cholesterol is the correct answer as it plays a crucial role in reducing the risk of cardiovascular disease by removing LDL cholesterol, whereas the other choices do not offer the same protective benefits.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.

Correct Answer: B

Rationale: The correct answer is B because a functional health assessment evaluates various health patterns such as roles, relationships, coping mechanisms, stress tolerance, and lifestyle choices, providing a holistic view of the individual's well-being. Vital signs and circulation (A) are typically included in a physical assessment, not a functional health assessment. Assessing specific organ abnormalities (C) would be part of a focused physical examination or diagnostic testing. Acute symptoms (D) are important to address but do not encompass the comprehensive evaluation of health patterns that a functional health assessment covers.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The initial priority in managing sepsis is to restore perfusion and oxygenation by giving IV fluids to support blood pressure and organ perfusion. This helps to improve tissue oxygenation and prevents further organ damage. Administering insulin (choice B) is not the priority in the initial management of sepsis. Monitoring blood pressure (choice C) is important but not the first step in the management of sepsis. Administering insulin is also listed twice and is not relevant to the immediate management of sepsis.