A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

Correct Answer: A

Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.

Correct Answer: A

Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.

Correct Answer: D

Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.

Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. This procedure allows direct visualization of the lower colon and rectum, enabling the detection of colorectal cancer. Stool hematest (A) detects blood in the stool but does not confirm cancer. Abdominal CT (B) can show abnormalities but is not specific for colorectal cancer. CEA scan (C) measures a tumor marker but is not definitive for diagnosis. Sigmoidoscopy (D) is the gold standard for diagnosing colorectal cancer as it allows for direct visualization and tissue biopsy.

Correct Answer: A

Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A. Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.

Correct Answer: B

Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.

Correct Answer: B

Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.

Correct Answer: B

Rationale: Correct Answer: B (High fat diet) Rationale: 1. Ketogenic diet for seizures aims to produce ketones for brain energy, achieved through high fat intake. 2. High fat intake helps induce ketosis, which may help reduce seizures in some children. Incorrect Choices: A: High carbohydrate diet - Contradicts the purpose of a ketogenic diet. C: High protein diet - Excessive protein can hinder ketosis and is not the primary focus of a ketogenic diet. D: Low fat diet - Opposite of the high fat requirement for a ketogenic diet to induce ketosis.

Correct Answer: A

Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.