in assessing a 70 year old female client with alzheimers disease the nurse notes that she has deep inflamed cracks at the corners of her mouth what in
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1. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?

Correct answer: D

Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.

2. A client with chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which intervention should the nurse implement first?

Correct answer: C

Rationale: In a client with COPD experiencing respiratory distress, the priority intervention should be to position the client in a high Fowler's position. This position helps optimize lung expansion, improve oxygenation, and reduce the work of breathing. Administering bronchodilators and encouraging pursed-lip breathing are important interventions but positioning the client to enhance respiratory function takes precedence in this situation. Obtaining an ABG sample may provide valuable information but is not the initial priority when addressing respiratory distress.

3. A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?

Correct answer: B

Rationale: A serum potassium level of 2.8 mEq/L is critically low and can cause cardiac arrhythmias, requiring immediate intervention. Hypokalemia is a life-threatening condition that needs prompt correction to prevent serious complications. High serum glucose levels (choice A) are a concern in diabetes but do not pose an immediate life-threatening risk compared to severe hypokalemia. Serum sodium (choice C) and serum bicarbonate levels (choice D) are within normal ranges and do not require immediate intervention.

4. The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?

Correct answer: C

Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.

5. A 60-year-old woman presents with fatigue, pruritus, and jaundice. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?

Correct answer: B

Rationale: The symptoms of fatigue, pruritus, jaundice, and elevated bilirubin and alkaline phosphatase levels are classic features of primary biliary cirrhosis, an autoimmune liver disease. Hepatitis C typically presents with different symptoms and findings, such as specific viral markers. Hemochromatosis and Wilson's disease involve iron overload and copper accumulation, respectively, leading to distinct clinical and laboratory findings, which do not match the presentation described in this case.

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