A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?

Correct Answer: D

Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.

Correct Answer: A

Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved. Step 2: Determines effectiveness of nursing interventions. Step 3: Validates if goals are met or adjustments are needed. Step 4: Reflects on the success of the care plan. Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care. Summary: - Choice B is incorrect as revising health history is part of assessment. - Choice C is incorrect as establishing priorities is part of the planning phase. - Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.

Correct Answer: B

Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions. Rationale for other choices: A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status. C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage. D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor. 2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences. 3. Standard precautions should always be maintained to prevent the spread of infections. 4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.

Correct Answer: D

Rationale: Step 1: Hypernatremia is defined by elevated serum sodium levels (>145mEq/L). Step 2: Serum osmolality of 245mOsm/kg is high, consistent with hypernatremia. Step 3: Urine specific gravity below 1.003 indicates dilute urine, a common finding in hypernatremia. Step 4: The combination of elevated serum sodium, high serum osmolality, and low urine specific gravity confirms hypernatremia. Summary: A: Incorrect, as high serum osmolality (not 245mOsm/kg) is associated with hypernatremia. B: Incorrect, as low urine specific gravity (not below 1.003) is seen in hypernatremia. C: Incorrect, as serum sodium needs to be >145mEq/L to indicate hypernatremia.