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: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting. Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.

Correct Answer: D

Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Abnormal involuntary movements are a hallmark feature, while cognitive decline and emotional disturbances are also commonly observed. Therefore, all three manifestations are typically present in individuals with Huntington's disease. Choices A, B, and C are incorrect because each of these symptoms alone does not encompass the full spectrum of clinical manifestations seen in Huntington's disease.

Correct Answer: A

Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation. Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control. Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided. Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects. Step 5: Daily multivitamin supplements do not directly impact blood pressure control.

Correct Answer: C

Rationale: Rationale: 1. Loratadine is typically dosed once daily, not twice daily, for allergic rhinitis. 2. Taking it twice daily may increase the risk of side effects without added benefit. 3. The client's dosing schedule reflects a misunderstanding of the medication regimen. 4. Option A is incorrect because loratadine is available in 10mg tablets. 5. Option B is incorrect as loratadine can be taken with or without food. 6. Option D is incorrect as Claritin is a common trade name for loratadine.