Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.

Correct Answer: A

Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.

Correct Answer: B

Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.

Correct Answer: C

Rationale: The correct answer is C: “Nurses use evaluation to determine the effectiveness of nursing care.” Evaluation in nursing is essential to assess the outcomes of nursing interventions and determine the effectiveness of the care provided. It helps in identifying areas for improvement, making informed decisions, and ensuring quality patient care. Choice A is incorrect because evaluation is not solely about checking completion of tasks but rather assessing the impact of those interventions on patient outcomes. Choice B is incorrect as evaluation is not related to staffing decisions but focuses on assessing the quality of care delivery. Choice D is incorrect as evaluation is not about eliminating paperwork but rather about improving care outcomes.

Correct Answer: D

Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure. Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling. Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications. Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.