Correct Answer: A

Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life. Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.

Correct Answer: C

Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?” Rationale: 1. Involving the family and physician ensures a collaborative decision-making process. 2. It respects the client's autonomy and involves them in the decision-making process. 3. It promotes open communication and support from loved ones. 4. It addresses the client's concerns about continuing treatment based on family wishes. Summary: A: Refers to psychological support, but the client's primary concern is medical treatment decisions. B: Involves religious support, which may not align with the client's beliefs or address the medical decision. D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.

Correct Answer: A

Rationale: The correct answer is A: Pneumocystis carinii pneumonia (PCP). PCP is the most common opportunistic infection in AIDS due to the weakened immune system, making patients vulnerable to this fungal infection. PCP is a leading cause of morbidity and mortality in AIDS patients. Toxoplasmosis (B) is also common but not as prevalent as PCP in AIDS. Candidiasis (C) is a common fungal infection but not the most common in AIDS. Mycoplasma pneumoniae (D) is a bacterial infection and not typically considered an opportunistic infection in AIDS.

Correct Answer: A

Rationale: The correct answer is A: Ambulating a patient. Direct care interventions involve hands-on activities directly impacting patient outcomes. Ambulating a patient is a direct care intervention as it involves physically assisting the patient to move, promoting circulation, preventing complications, and improving overall well-being. Inserting a feeding tube (B) and performing resuscitation (C) are also direct care interventions as they involve immediate patient care actions. Documenting wound care (D) is not a direct care intervention as it involves recording information about a care activity rather than physically performing the care itself.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.