Which symptom may appear first in an 80-year-old client diagnosed with pneumonia?

Correct Answer: A

Rationale: The correct answer is A: Altered mental status and dehydration. In elderly patients with pneumonia, altered mental status and dehydration are often the first symptoms due to age-related changes in the body's response to infection. Dehydration can lead to electrolyte imbalances affecting brain function. Fever and chills (B) typically follow as the infection progresses. Hemoptysis and dyspnea (C) are less common in elderly pneumonia patients. Pleuritic chest pain and cough (D) usually occur later in the course of the illness.

Correct Answer: C

Rationale: The correct answer is C: To determine the extent of lesions. A chest X-ray is ordered for a client with a positive Mantoux test to assess the presence and extent of any lesions in the lungs, which may indicate active tuberculosis disease. This helps in determining the severity of the infection and guiding appropriate treatment. Explanation for incorrect choices: A: Chest X-ray does not confirm the diagnosis of tuberculosis, as other diagnostic tests like sputum culture are needed. B: A repeat skin test is not determined by a chest X-ray but by guidelines based on the initial Mantoux test result. D: Chest X-ray does not differentiate between primary and secondary infection, as this distinction is typically based on clinical history and other factors.

Correct Answer: A

Rationale: The correct answer is A: Away from the body. This is because opening the first flap away from the body reduces the risk of contaminating the sterile contents inside the package. By opening the flap away from the body, any potential contaminants on the outside of the envelop such as dust or germs are less likely to come in contact with the sterile items inside. Opening the flap in any other direction (B, C, or D) increases the chances of introducing contaminants into the sterile package, compromising its sterility. It is crucial to follow proper aseptic techniques to maintain the sterility of medical supplies and prevent infections.

Correct Answer: D

Rationale: The correct answer is D: Anisocoria. Anisocoria refers to unequal pupil size, which can be a result of various conditions affecting the eye or nervous system. The term "enteric" (A) refers to the intestines, not pupil size. Diplopia (B) is double vision, not unequal pupil size. Anecteric (C) is not a recognized medical term related to pupil size. Therefore, choice D is the correct answer as it specifically addresses the condition of unequal pupil size.

Correct Answer: B

Rationale: The correct answer is B: Call the doctor immediately. This is the most important nursing action because severe pain after a renal biopsy could indicate a serious complication such as internal bleeding or organ damage, which requires prompt medical intervention. Calling the doctor ensures timely assessment and appropriate treatment. Rationale for other choices: A: Assess for malingering - In this context, assuming the client is faking or exaggerating pain can delay necessary medical attention. C: Assess pain scale - While important, assessing pain scale alone does not address the urgency of the situation. D: Give analgesic as ordered - Administering pain medication without consulting the doctor first could mask symptoms of a serious complication and delay proper treatment.