Correct Answer: B

Rationale: The correct answer is B: Arm and leg trembling. With a blood glucose level of 470 mg/dl in a client with type I diabetes mellitus, the most likely finding is arm and leg trembling, which is a common symptom of hypoglycemia. This occurs due to the body's response to low blood sugar levels, causing tremors as a compensatory mechanism to increase glucose utilization. The other choices are incorrect because cool, moist skin is a sign of hypoglycemia, rapid thready pulse is a sign of shock or hypovolemia, and slow shallow respirations are not typically associated with high blood glucose levels in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (
A) is a symptom, not a diagnosis. Sleep apnea (
C) and heart failure (
D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.

Correct Answer: B

Rationale: The correct answer is B: Acute pain. This is the only choice that aligns with NANDA-I approved nursing diagnoses. Acute pain is a common nursing diagnosis that focuses on addressing a patient's immediate discomfort. NANDA-I emphasizes the importance of using standardized nursing diagnoses to improve communication and ensure proper interventions. Sore throat (
A) and sleep apnea (
C) are symptoms or medical diagnoses, not specific nursing diagnoses. Heart failure (
D) is a medical diagnosis and not a NANDA-I approved nursing diagnosis.

Correct Answer: B

Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data.

Summary:
- A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse.
- C: Secondary data are information obtained from other sources, not directly from the client.
- D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.

Correct Answer: A

Rationale: Rationale for Correct Answer (
A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.

Summary of Incorrect

Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.