A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?

Correct Answer: B

Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.

Correct Answer: D

Rationale: Step-by-step rationale for choosing answer D as correct: 1. Acknowledges patient's withdrawn behavior 2. Demonstrates empathy and concern 3. Open-ended question allows patient to express feelings 4. Encourages patient to communicate concerns Summary: - Option A assumes a specific problem without patient input - Option B focuses on verbalization, not necessarily addressing underlying concerns - Option C makes assumptions about patient's worries without allowing him to express himself

Correct Answer: C

Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.

Correct Answer: B

Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. This ensures patient-centered care and respects the patient's autonomy. Speaking only to the daughter may undermine the patient's dignity and may lead to incomplete information gathering. Choices A, C, and D are incorrect as they are appropriate nursing communication techniques that facilitate rapport-building and active listening with the patient. Making eye contact, leaning forward, and nodding are all positive non-verbal cues that show engagement and attentiveness to the patient, promoting effective communication and building trust.

Correct Answer: D

Rationale: The correct answer is D, the bicarbonate-carbonic system. This buffer system is crucial in maintaining the body's pH balance. When CO2 combines with water in the blood, it forms carbonic acid, which dissociates into bicarbonate ions and hydrogen ions. Bicarbonate acts as a base, accepting excess hydrogen ions to prevent a decrease in pH. Hemoglobin and plasma proteins primarily function as transport molecules, not as buffer systems. Phosphate buffer system is present in intracellular fluids, not as commonly in the body. The bicarbonate-carbonic system is the most prevalent buffer system in the blood and plays a vital role in regulating blood pH.

Correct Answer: C

Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.

Correct Answer: B

Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.

Correct Answer: A

Rationale: Step 1: Assess the client's vital signs to confirm presence of fever. Step 2: Measure client's oral temperature to obtain accurate reading. Step 3: Document temperature and report findings to healthcare provider. Step 4: Initiate appropriate interventions based on temperature reading. Step 5: Reassess client's condition to evaluate effectiveness of interventions. Summary: Option A is correct as it directly addresses the cue of fever by confirming the temperature. Options B, C, and D are incorrect as they do not directly address the need to assess the client's temperature for accurate evaluation and intervention.

Correct Answer: D

Rationale: The correct answer is D because antimetabolites interfere with the synthesis of nucleic acids (RNA and/or DNA), affecting multiple stages of RNA and DNA synthesis. This disruption hinders cell division and leads to cell death. Choices A and B are incorrect because antimetabolites do not specifically target cell division during the M phase or normal cellular processes during the S phase. Choice C is also incorrect because antimetabolites primarily target nucleic acid synthesis rather than altering the chemical structure of DNA or the binding between DNA molecules.