A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

Correct Answer: C

Rationale: Planning for the baby reflects anticipation, typical in late pregnancy.

Correct Answer: A

Rationale: Female growth spurts typically precede males' by about 2 years (around age 11-12).

Correct Answer: B

Rationale: Regular range-of-motion exercises are vital to prevent complications like joint stiffness, muscle atrophy, and blood clots in patients with limited mobility post-surgery. These exercises maintain circulation and flexibility, countering the risks of prolonged stillness. Avoiding hydration increases dehydration risk and doesn't address immobility's effects it's counterproductive. Keeping the patient supine at all times exacerbates immobility issues, potentially leading to pressure ulcers or respiratory problems. Minimizing communication might reduce stress but doesn't tackle physical complications. Nurses use active or passive exercises depending on the patient's ability, ensuring joints stay functional and reducing the likelihood of thromboembolism or contractures, which are serious post-operative concerns.

Correct Answer: D

Rationale: A thorough physical examination provides a comprehensive assessment of nutritional status by evaluating signs like muscle wasting, skin condition, hair health, and edema, alongside weight and lab data. Family dietary reports are subjective and incomplete without clinical correlation. Relying only on weight misses underlying issues like fluid retention or muscle loss. Monitoring intake and output tracks fluid balance but not nutrient absorption or deficiencies. A full exam integrates physical findings with history and tests, offering a holistic view critical for identifying malnutrition or overnutrition and guiding tailored interventions in nursing care.

Correct Answer: D

Rationale: Using handrails and non-slip mats reduces fall risk in patients with impaired mobility by providing physical support and traction, countering weakness or unsteadiness. Walking unassisted heightens danger, especially without strength or balance. A dark room obscures hazards, increasing falls rather than preventing them rest doesn't trump safety. Placing items out of reach forces risky stretching or movement. Nurses implement these environmental aids to create a secure space, empowering safe mobility and minimizing injury, a critical aspect of care for vulnerable patients.