While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client’s chart. Which of the following actions clearly demonstrates assessing?

Correct Answer: C

Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.

Correct Answer: B

Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.

Correct Answer: B

Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention. Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless. Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand. Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.

Correct Answer: C

Rationale: The correct answer is C: Memory cells. After recovery from a disease, memory cells are formed as part of the adaptive immune response. These memory cells "remember" the pathogen and can mount a quicker and stronger immune response upon re-exposure. This results in immunity to the disease. Antigens (choice A) are substances that trigger the immune response but do not provide immunity on their own. Complement (choice B) is a group of proteins that enhance the immune response but do not directly lead to immunity. Natural killer cells (choice D) are part of the innate immune system and are not responsible for the specific memory response needed for immunity.

Correct Answer: B

Rationale: The correct answer is B, Middle ear. This is because the middle ear is the most common site for ear infections due to its anatomy, including the Eustachian tube that can easily become blocked, leading to fluid buildup and infection. The outer ear (A) is less susceptible to infections, while the inner ear (C) and semicircular canal (D) are not typically involved in ear infections, as they are more related to balance and hearing functions rather than infection susceptibility.

Correct Answer: B

Rationale: The correct action is to administer antibiotics as ordered first because pelvic inflammatory disease is caused by an infection, usually from sexually transmitted organisms. Administering antibiotics promptly is crucial to prevent further complications and treat the underlying infection. This helps to alleviate the source of the pain. Rating pain severity, administering analgesics, and patient education are important but should come after addressing the infection to prevent worsening of the condition.

Correct Answer: C

Rationale: The correct answer is C because crushing or breaking tablets can alter the medication's effectiveness or cause harm. Step 1: Consult a physician or pharmacist ensures safety and effectiveness. Step 2: This step helps in determining if the medication can be safely altered for easier swallowing. Step 3: Using liquid form (B) may not always be an option. Mixing with food (A) can affect absorption. ROM exercises (D) are unrelated to medication administration.

Correct Answer: B

Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and potentially disrespectful attitude towards the nurse. This response does not promote a collaborative and respectful communication between the daughter and the nurse. In a healthcare setting, it is important for family members to communicate effectively and respectfully with the healthcare team to ensure the best care for the patient. A: This statement shows understanding and acceptance of the symptoms of the disease, indicating good knowledge. C: This statement shows willingness to help the patient with tasks he cannot do for himself, which is a positive and caring attitude. D: This statement shows consideration for the patient's needs by planning to turn off the TV when moving to another room, which is appropriate.