The correct answer is choice C. Red welts widespread over the chest.

Choice A rationale:

Ulceration on the corner of the upper lip does not indicate a need for loratadine administration. Loratadine is an antihistamine commonly used to relieve symptoms of allergies such as sneezing, runny nose, and itchy or watery eyes. Ulceration on the lip is not associated with an allergic reaction.

Choice B rationale:

Ecchymosis and petechiae on the legs are not related to the need for loratadine. These findings suggest potential bleeding or clotting disorders, and loratadine does not address such issues.

Choice C rationale:

Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.

Choice D rationale:

Red papules and pustules on the face are unlikely to be treated with loratadine. These skin manifestations may be related to various dermatological conditions, but not necessarily allergic reactions that loratadine is primarily used to manage.

Choice A rationale:

Blood glucose level of 271 mg/dL falls within the range of 270 to 300 mg/dL, which corresponds to a sliding scale dose of 15 units.

Choice B rationale:

Oxygen saturation measurement is not relevant to the calculation of insulin dosage in this scenario, so it is not the most important information for the nurse to consider when determining the insulin dose.

Choice C rationale:

The client's orientation status is also not directly related to the insulin dosage, making it less important in this context.

Choice D rationale:

Urinary output of 50 mL/hour is not relevant to the calculation of insulin dosage, so it is not the most critical information for the nurse to consider.

Safety plan to keep in a purse at all times.

Choice A rationale:

The practical nurse (PN) should provide the client with a safety plan to keep in her purse at all times. Safety planning is crucial for individuals facing domestic abuse, and having a plan readily available can be a lifesaving resource. This plan should include emergency contact numbers, information about local women's shelters, steps to take during an abusive incident, and strategies for safely leaving an abusive situation. By giving the client a safety plan, the PN empowers her with tools to protect herself and her unborn child.

Choice B rationale:

While providing paperwork for filing a restraining order may be an important step for the client's safety, it may not be the first action the PN should take. Filing a restraining order requires a legal process, which might not provide immediate protection in the event of an escalating abusive situation.

Choice C rationale:

Documenting the report of abuse in the visit summary is essential for legal and documentation purposes, but it does not directly address the client's safety needs. The PN should prioritize assisting the client in creating a safety plan to protect herself and her unborn

child from potential harm. Choice D rationale:

Providing contact information for a women's shelter is a supportive measure for the client, but it might not be the immediate first action to take. The client should be educated on developing a safety plan first, and then, if she decides to seek refuge in a women's shelter, the contact information can be utilized.

Choice A rationale:

Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.

Choice B rationale:

Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.

Choice C rationale:

Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.

Choice D rationale:

Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.

Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.

The other options are not correct because:

A. Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.

B. Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve airway patency.

D. Encouraging the child to drink adequate amounts of fluids may help prevent dehydration and thin the secretions, but it does not relieve the inflammation or narrowing of the airway.

The correct answer is choice D, Pupils reactive to accommodation. Choice A rationale:

"Peripheral vision intact”. refers to the ability to see objects at the outer edges of one's visual field. It is not relevant to the assessment of pupillary response and does not describe the finding of pupils constricting as they change focus from a far object to a near object.

Choice B rationale:

"Nystagmus present with pupillary focus”. suggests involuntary rapid eye movements accompanied by changes in pupillary response. Nystagmus is not an expected finding during pupillary accommodation, and its presence would indicate a neurological issue rather than a normal response.

Choice C rationale:

"Consensual pupillary constriction present”. refers to both pupils constricting when light is shined into one eye. While this finding is normal, it does not specifically describe the pupils' response during accommodation when focusing from a far object to a near object.

Choice D rationale:

"Pupils reactive to accommodation”. accurately describes the normal physiological response of the pupils constricting as they change focus from a distant object to a nearby object. This response ensures that the appropriate amount of light enters the eyes to maintain clear vision during different distances of focus.

In the absence of specific medical guidelines or orders, and considering the heart rate of 120 beats per minute, the generally appropriate course of action for a practical nurse might be to administer the medication as ordered by the healthcare provider. Therefore, the correct choice could be:

b) Administer the medication and document the heart rate.

However, it's crucial to emphasize that the nurse should always follow the specific orders and guidelines of the healthcare provider and the facility's protocols. If there is any uncertainty or concern, the nurse should seek guidance from the charge nurse or the healthcare provider before taking any action.

a) Hold the medication and recheck the heart rate in 1 hour:

• Rationale: This option suggests delaying the administration of the medication without clear justification. If the healthcare provider has prescribed the medication and the heart rate is within an acceptable range, delaying it without a specific reason may not align with the provider's instructions.

c) Administer the medication and alert the charge nurse:

• Rationale: Administering the medication and immediately alerting the charge nurse without a clear indication of a problem might create unnecessary concern or confusion. The nurse should follow the established protocols and guidelines, and if there are concerns, consulting with the healthcare provider may be more appropriate before alerting others.

d) Hold the medication and document cardiac assessment:

• Rationale: This option involves holding the medication without clear justification or evidence of a contraindication. If the heart rate is within the acceptable range and the healthcare provider has ordered the medication, holding it without proper reason might not be in line with best practices.

It's important to note that the appropriateness of actions depends on the specific clinical context, healthcare provider's orders, and facility protocols. Always consult with a healthcare professional or follow the established guidelines in your healthcare setting.

This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's attention to another topic or activity and document the incident.

A. The size of my breasts is of no concern to you is not the best response because it may sound defensive or sarcastic and may not deter the adolescent from making similar comments in the future.

C. Do you really think so? is not the best response because it may encourage or reinforce the adolescent's inappropriate or sexual comments and may imply that the PN is interested or flattered by them.

D. If you talk like that again, I will tell your parents is not the best response because it may sound threatening or punitive and may not address the underlying issue of the adolescent's behavior. The PN should inform the parents only if the behavior persists or escalates.

This is the best action for the PN to take because it provides immediate relief for the client's pain, which can be severe and debilitating in Herpes zoster. The PN should also assess the client's pain level, location, and characteristics and document the response to the medication.