Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.

Correct Answer: D

Rationale: The correct answer is D because systemic lupus erythematosus can lead to inflammation in the lungs, causing abnormal lung sounds. Dysphagia (choice A) is not typically associated with lupus. Dryness or itching of genitalia (choice B) is more characteristic of conditions like yeast infections or dermatitis. Decreased visual acuity or blindness (choice C) is not a common manifestation of lupus. Abnormal lung sounds (choice D) are commonly seen in lupus patients due to inflammation and possible lung involvement.

Correct Answer: B

Rationale: The correct answer is B: helicobacter pylori infection. This bacterium is a major cause of peptic ulcers by weakening the protective mucous layer of the stomach and duodenum. Research has shown a strong association between H. pylori infection and peptic ulcer development. Genetic defects in the gastric mucosa (choice A) are not a proven cause of peptic ulcers. While a high-fat diet (choice C) can exacerbate symptoms, it is not the primary cause. Work-related stress (choice D) may exacerbate symptoms but is not a direct cause of peptic ulcers. Therefore, choice B is the most supported and logical answer based on current research findings.

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: A

Rationale: Rationale: 1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit. 2. This step helps determine if the lack of response is due to a sensory issue. 3. It allows the nurse to rule out unilateral neglect or hemianopsia. 4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients. Other Choices: B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing. C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits. D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.