A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?

Correct Answer: D

Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively. A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem. C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem. D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.

Correct Answer: C

Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem. Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.

Correct Answer: C

Rationale: The correct answer is C: “This type of surgery rarely affects the ability to have an erection or ejaculation.” This response is appropriate because it provides accurate information that addresses the patient's concern about sexual function without making any false claims. TURP (Transurethral Resection of the Prostate) typically does not impact a patient's ability to have an erection or ejaculate. This reassurance can help alleviate the patient's fears and provide him with accurate information to make an informed decision. Explanation for why the other choices are incorrect: A: “Don’t worry about sterility; sperm production is not affected by this surgery.” - This is incorrect as the concern is more about sexual function than sterility. B: “Would you like some information about implants used for impotence?” - This is incorrect as it jumps to a solution without addressing the patient's specific concern about TURP affecting sexual function. D: “There are many methods of sexual expression that are alternatives to sexual intercourse