A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

A. Measure the intake and output of a client who has received furosemide: Measuring intake and output is within the scope of practice for assistive personnel. The nurse remains responsible for interpreting the data and notifying the provider of any concerns.

B. Check a client's peripheral IV site for redness or swelling: Assessment of IV sites for complications such as infiltration, phlebitis, or infection requires clinical judgment and should be performed by licensed nursing personnel.

C. Assess the pain level of a client who has received acetaminophen: Pain assessment requires clinical judgment, interpretation of client responses, and knowledge of pain scales. Only licensed nurses should perform pain assessments and determine the effectiveness of interventions.

D. Reinforce teaching with a client about crutch-gait walking: Reinforcing teaching involves understanding and communicating clinical concepts accurately. Even though it may seem routine, instructing or clarifying a gait technique requires nursing knowledge to ensure client safety and proper technique.

A. Leave the needle in place for 10 seconds after the injection: Leaving the needle in place for approximately 10 seconds after administering a subcutaneous injection helps ensure full delivery of the medication and reduces the chance of medication leakage at the injection site.

B. Use a 5-inch needle for the injection: A 5-inch needle is excessively long for subcutaneous injections and would likely penetrate muscle tissue, increasing the risk of injury or incorrect medication administration. Subcutaneous injections typically require a needle length between ⅜ and ⅝ inch.

C. Inject the medication using the Z-track technique: The Z-track technique is used for intramuscular injections to minimize medication leakage and reduce irritation. It is not appropriate for subcutaneous injections, which are administered into the fatty layer beneath the skin, not deep muscle tissue.

D. Insert the syringe at a 15° angle during injection: A 15° angle is used for intradermal injections. Subcutaneous injections should be administered at a 45° to 90° angle depending on the client’s body mass to ensure the medication is delivered into the subcutaneous tissue, not the dermis or muscle.

A. An assistive personnel is late for the upcoming shift: Tardiness is an issue of staff performance or scheduling rather than client safety, and it should be addressed through administrative or managerial processes. It does not require an incident report unless it directly results in harm or neglect to a client.

B. A client refuses to eat at mealtime: Client refusal to eat is a common occurrence and is managed through nutritional assessments and care planning. While it should be documented in the medical record, it does not constitute an unusual or adverse event that requires an incident report.

C. A family member is napping in the client's room: A family member resting in the room is not an incident unless it interferes with care or violates facility policy. This situation is not associated with client harm or safety risk, so it does not meet the criteria for incident reporting.

D. A client's bed alarm is malfunctioning: A malfunctioning bed alarm is a safety issue, particularly for clients at risk of falls. It represents a potential hazard that could lead to client injury, making it necessary to complete an incident report to document the problem and prompt timely intervention or equipment repair.

A. Instruct the client to blink his eyes as a response: Expressive aphasia affects a person's ability to speak or write, but comprehension is often intact. Encouraging nonverbal communication methods such as blinking for "yes" or "no" responses can help the client effectively express needs and participate in care decisions without requiring speech.

B. Increase voice volume when speaking to the client: Raising the volume does not assist clients with expressive aphasia, as their difficulty lies in expression rather than hearing. Speaking louder can be perceived as frustrating or disrespectful and may not improve understanding or communication for the client.

C. Avoid using hand gestures: Hand gestures and facial expressions can enhance communication for individuals with aphasia by providing visual cues. Avoiding gestures removes a valuable tool that may help the client interpret and respond to messages, especially when they cannot verbalize thoughts.

D. Enunciate words slowly: While speaking clearly is beneficial in many communication disorders, expressive aphasia primarily impairs output, not comprehension. Enunciating slowly may not help the client respond more effectively and is more useful in receptive or global aphasia cases.

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.

A. "I should stop receiving Papanicolaou tests once I reach menopause”: Discontinuing Pap tests solely based on menopause is not recommended. Screening continues until at least age 65, depending on the individual's health history and prior screening results. Regular cervical cancer screening is important for early detection, even after menstruation stops.

B. "I might have headaches due to a decline in my estrogen levels”: Fluctuating and declining estrogen levels during perimenopause can trigger headaches or worsen existing ones. Hormonal changes affect blood vessels and neurotransmitters, contributing to the development of migraines or tension headaches in many women during this stage.

C. "The best time to perform a breast self-examination is on the first day of my period”: The ideal time is 7 to 10 days after the start of the menstrual period, when hormonal influence on breast tissue is minimal. Performing it on the first day of menstruation may result in increased tenderness and swelling, making it harder to detect abnormalities.

D. "I can expect to have regular periods until I am in menopause.": Perimenopause is typically marked by irregular menstrual cycles due to hormonal shifts. Periods may become lighter, heavier, more or less frequent before stopping altogether.

A. Gather additional information from the caller to verify their identity: Even if the caller's identity is verified, HIPAA regulations prohibit disclosing a client's medical information without the client’s explicit authorization. Verifying identity alone does not grant permission to release confidential health information.

B. Request that the caller contact the client's provider directly for information: Redirecting the caller to the provider does not resolve the issue of confidentiality. Healthcare providers are also bound by HIPAA regulations and cannot release information without proper consent, regardless of who is making the request.

C. Ask the caller to contact the client directly for information: This action respects the client’s privacy and autonomy. Under HIPAA, healthcare professionals may not disclose health information without client authorization. Advising the sibling to speak directly with the client is the appropriate response to safeguard confidentiality.

D. Provide the caller with a brief update about the client's condition: Sharing any health information without the client’s express consent is a violation of HIPAA. Even a brief update constitutes a breach of confidentiality and could result in legal and professional consequences.

A. Registered dietitian: A dietitian can assess nutritional needs and recommend appropriate diets based on swallowing ability, but they do not directly evaluate or treat swallowing disorders. Their role becomes relevant after the dysphagia has been assessed and a safe diet established.

B. Respiratory therapist: Respiratory therapists focus on managing breathing and airway clearance, which can be important if aspiration pneumonia occurs. However, they do not assess or treat the swallowing difficulties themselves.

C. Speech-language pathologist: Speech-language pathologists evaluate and treat swallowing disorders as well as communication impairments following stroke. They perform swallowing assessments and develop individualized therapy plans to improve swallowing safety and function.

D. Occupational therapist: Occupational therapists assist clients with regaining independence in activities of daily living but do not specialize in swallowing assessments or treatments. Their focus is more on motor skills, cognition, and adaptive strategies.

A. Bear weight on the unaffected leg: In a three-point gait, the client bears weight only on the unaffected leg while advancing both crutches and the affected leg together. This gait pattern is used when one leg is non-weight-bearing or injured, ensuring safety and stability during ambulation.

B. Stand with the crutch tips against the feet: Crutch tips should be positioned about 6 inches to the side and slightly in front of the feet to provide a stable base of support. Placing crutches directly against the feet increases the risk of slipping and instability.

C. Hold the arms straight when walking: Arms should be slightly flexed at the elbows when holding crutches to absorb shock and reduce strain. Holding the arms straight can cause fatigue and reduce control during walking.

D. Keep the crutches at the level of the axillae: Crutches should be adjusted to about 1 to 2 inches (2.5 to 5 cm) below the axillae to prevent pressure on the nerves and blood vessels in the armpits, which could cause nerve damage or circulatory problems.