A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment would the nurse perform first?

Correct Answer: C

Rationale: Soft food preference and constipation suggest dental issues, per the document, making oral assessment first to check dentures or teeth. Bowel sounds follow, skin turgor assesses hydration, and weight tracks nutrition secondary steps. C identifies the cause, guiding intervention, making it the priority.

Correct Answer: D

Rationale: Walking Meditation is a mindfulness practice rooted in Buddhist traditions, emphasizing awareness and calm. It's not about rapid breathing or pressure points , nor fast-paced walking for fitness , which contradicts its meditative purpose. It also doesn't involve music , as the focus is on bodily awareness, not external stimuli. The correct answer, D, captures its essence: slow, deliberate walking paired with deep breathing to foster relaxation and present-moment awareness. This practice reduces stress by engaging the parasympathetic nervous system, lowering heart rate, and enhancing mental clarity, making it distinct from exercise or other stress-reduction methods.

Correct Answer: C

Rationale: Establishing a therapeutic relationship requires self-awareness as the foundation. Being aware of one's personality and self-talk allows the nurse to manage biases and emotions, ensuring interactions remain client-centered. Avoiding labeling is important but secondary to self-awareness, which prevents labeling in the first place. A review of systems is clinical, not relational, and understanding the client's response comes after engaging with them. Self-awareness, per Peplau and therapeutic models, enables empathy and professionalism, preventing countertransference and fostering trust, making C the critical first step in care provision.

Correct Answer: C

Rationale: Stress from looming deadlines can lead to immunosuppression , weakening the immune system and increasing susceptibility to infections like a sore throat and fever. Decreased energy and sleep deprivation may contribute but are less specific causes of illness; they're symptoms of stress, not the mechanism. Exposure to streptococcus could be a factor, but the question ties illness to her situation, not a specific pathogen. Chronic stress elevates cortisol, suppressing T-cell activity and antibody production, making C the most direct link between her circumstances and illness onset.

Correct Answer: C

Rationale: Regression involves reverting to earlier developmental behaviors, like bed-wetting, under stress here, a new sibling's arrival. Identification is adopting others' traits, rationalization is justifying actions, and repression is blocking memories. Regression fits as the child copes with jealousy or loss of attention by retreating to infantile behavior, a common psychological response to perceived threats, making C the correct mechanism.