A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

Correct Answer: D

Rationale: Deep-vein thrombosis (DVT) involves a blood clot in a deep vein, typically in the leg, obstructing venous return and causing impaired blood flow. The nursing diagnosis 'Altered peripheral tissue perfusion related to venous congestion' (Choice D) takes priority because it directly addresses the primary pathophysiological issue: reduced circulation distal to the clot, risking tissue ischemia or infarction. Impaired gas exchange (Choice A) is incorrect because DVT primarily affects venous, not arterial, flow, and gas exchange relates to pulmonary issues like embolism, not the initial DVT state. Fluid volume excess (Choice B) isn't indicated, as DVT doesn't inherently cause systemic fluid overload; edema is localized. Risk for injury related to edema (Choice C) is a concern but secondary, as it's a symptom rather than the core problem. Prioritizing tissue perfusion aligns with the ABCs (airway, breathing, circulation) and Maslow's hierarchy, where physiological needs like circulation supersede safety risks. If untreated, poor perfusion can lead to tissue damage or pulmonary embolism, making Choice D the most urgent and correct diagnosis.

Correct Answer: A

Rationale: A high-protein diet emphasizes foods rich in amino acids for tissue repair, muscle maintenance, or recovery. Baked beans, hamburger, and milk (Choice A) are protein powerhouses: beans (7-10 g/cup), hamburger (20-25 g/patty), and milk (8 g/cup) total over 35 g per meal, far exceeding others. Spaghetti with cream sauce, broccoli, and tea (Choice B) leans carbohydrate-heavy (pasta), with broccoli offering minimal protein (3 g/cup) and tea none. Bouillon, spinach, and soda (Choice C) provide negligible proteinspinach has 5 g/cup, but bouillon and soda contribute little. Chicken cutlet, spinach, and soda (Choice D) include protein from chicken (25-30 g), but spinach and soda add little, totaling less than Choice A. For a client needing 50-60 g daily, Choice A's variety and quantity signal successful teaching, making it the correct answer.

Correct Answer: B

Rationale: Sleep is a natural, recurring state distinct from wakefulness, and its definition hinges on physiological and perceptual changes. 'Altered consciousness, relative inactivity' best captures this, reflecting sleep's reduced awareness and minimal physical movement, as seen in EEG shifts from beta to delta waves during non-REM stages. Choice A, 'decreased state of activity, refreshed,' partially appliesactivity drops, and waking often refreshesbut it omits the critical consciousness shift, making it incomplete. Choice C, 'comatose, immobility,' describes a pathological state, not normal sleep; coma lacks the reversibility and cycles (REM/NREM) of sleep. Choice D, 'alert, responsive,' defines wakefulness, the opposite of sleep. For example, during NREM stage 3, a sleeper's consciousness alters (less responsive to stimuli), and muscle tone decreases, yet they can awakenunlike coma. Nursing texts like Taylor's Fundamentals emphasize sleep as a dynamic state of altered consciousness with reduced, not absent, activity, aligning with circadian biology. Thus, Choice B is the most accurate and comprehensive descriptor.

Correct Answer: B

Rationale: Exercise impacts sleep via arousal and body temperature effects, and timing matters. 'Exercise within 2 hours of bedtime can hinder ability to sleep' is correct; it raises heart rate, adrenaline, and core temperaturee.g., a 7 p.m. run might delay sleep onset from 10 p.m. to midnightcountering melatonin's cooling effect. Choice A, 'exercise immediately before bedtime enhances ability to sleep,' is false; while exercise generally aids sleep, late timing stimulates, not sedates, per sleep research (e.g., ACSM guidelines). Choice C, 'the time of day does not matter,' ignores circadian rhythm; morning or afternoon exercise (e.g., 3 p.m.) boosts sleep quality without delay. Choice D, 'the fatigue from exercise may be a hindrance,' misattributes; fatigue aids sleep if timed right (e.g., 5 p.m.). Nurses teach patients to finish vigorous activity 3-4 hours before bed, per Taylor, making Choice B the correct guidance.

Correct Answer: C

Rationale: Narcolepsy, a neurological disorder, disrupts sleep-wake regulation due to orexin loss. 'Uncontrollable desire to sleep' is its hallmarke.g., sudden sleep attacks lasting 10-30 minutes, even mid-conversationper DSM-5. 'Waking during sleep' is vague; narcolepsy involves cataplexy or hallucinations, not just waking. 'Restless leg syndrome' causes leg discomfort, unrelated to narcolepsy's sleepinesse.g., no daytime attacks. 'Decrease in the amount or quality of sleep' fits insomnia; narcoleptics sleep enough but fragmentedlye.g., 8 hours feel unrestful. A nurse might note a patient dozing during an exam, per Taylor's description of hypersomnia disorders. Choice C captures narcolepsy's defining trait correctly.