A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Correct Answer: B

Rationale: The correct answer is B: Make recommendations for revising the plan of care. When client outcomes are not met within the specified time frame, the nurse should reassess the plan of care to identify any potential reasons for the lack of progress. By making recommendations for revising the plan of care, the nurse can adjust interventions to better align with the client's needs and facilitate goal achievement. Continuing to follow the written plan of care (choice A) without modification may not address the underlying issues preventing goal attainment. Asking another health care professional to design a plan of care (choice C) may not be necessary if the nurse can assess and revise the current plan. Stating 'goal will be met at a later date' (choice D) does not address the need for immediate action to reassess and modify the plan for better outcomes.

Correct Answer: B

Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment. A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates. C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society. D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.

Correct Answer: A

Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.

Correct Answer: D

Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put strain on the surgical incision site and increase the risk of complications. A: Incorrect, as the head of the bed should be elevated to reduce swelling and promote drainage. B: Incorrect, as deep breathing and coughing are important to prevent pneumonia and promote lung expansion. C: Incorrect, as swallowing may be difficult initially but should improve gradually.

Correct Answer: C

Rationale: Step 1: Classic full-blown AIDS presents with tumors and opportunistic infections due to severe immune system suppression. Step 2: These manifestations occur when CD4 cell count drops significantly, leading to inability to fight infections. Step 3: Persistent generalized lymphadenopathy (Choice A) can be seen in early HIV infection, not necessarily in full-blown AIDS. Step 4: Sudden weight loss, fever, and malaise (Choice B) are non-specific symptoms seen in various conditions, not specific to AIDS. Step 5: Fever, weight loss, night sweats, and diarrhea (Choice D) are common symptoms but lack the specificity of tumors and opportunistic infections seen in classic full-blown AIDS.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Acute bronchitis is characterized by inflammation of the bronchial tubes. 2. An initial sign of acute bronchitis is a nonproductive cough due to irritation of the bronchial tubes. 3. Anorexia and labored breathing may occur later as the condition progresses. 4. Gastric ulceration is not typically associated with acute bronchitis. Therefore, choice A (Nonproductive cough) is the correct answer as it aligns with the characteristic symptom of acute bronchitis, while the other choices are not typically observed in the initial stages of the condition.

Correct Answer: B

Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.

Correct Answer: D

Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.