A nurse is assessing a client who experiences occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How would the nurse interpret the client's behaviors?

Correct Answer: D

Rationale: Step 1: The client is experiencing feelings of sadness due to a specific trigger, the death of a pet. Step 2: The client's appetite, sleep, and routine remain unchanged, suggesting no significant functional impairment. Step 3: Occasional feelings of sadness are a normal human response to loss and not indicative of mental illness. Step 4: The absence of significant impairment in daily functioning aligns with the absence of mental illness. Step 5: Therefore, the nurse would interpret the client's behaviors as demonstrating no functional impairment, indicating no mental illness. Other options are incorrect: A and B assume mental illness without evidence, and C is irrelevant to the situation.

Correct Answer: B

Rationale: The correct answer is B because a cold left foot with an absent pedal pulse could indicate compromised blood flow, which is concerning for potential vascular compromise or development of a blood clot post ORIF. This observation warrants immediate medical attention to prevent serious complications such as ischemia or thrombosis. Choices A, C, and D are not as urgent as they do not directly indicate potential vascular compromise or circulatory issues. A partially soiled dressing (Choice A) may require changing but does not indicate immediate danger. Limited functional anatomic position (Choice C) may be addressed with repositioning but does not signal an emergency. Normal blood pressure and pulse rate (Choice D) are within acceptable ranges and do not raise immediate concerns.

Correct Answer: C

Rationale: The correct answer is C: It obtained permit to operate from DOH. This is because the Records Management and Archives Office of the DOH is responsible for implementing record disposal policies for institutions that are under the jurisdiction of the Department of Health. Obtaining a permit to operate from the DOH indicates that the institution is recognized and regulated by the department, making it subject to the record disposal policies. Choices A, B, and D are incorrect as they do not directly relate to the institution being covered by the record disposal policy of the DOH.

Correct Answer: A

Rationale: The correct answer is A: Localized heat and redness. This is because heat and redness are classic signs of inflammation, which can indicate an infection developing in a surgical incision. The increased blood flow to the area causes heat, and the dilation of blood vessels causes redness. Serosanguinous exudates (choice B) and separation of the incision (choice C) are more indicative of normal wound healing or other complications rather than infection. Blood clots and scar tissue (choice D) are not typical signs of impending infection.

Correct Answer: C

Rationale: The correct answer is C: Take a video of the entire intra-operative procedure. This is not part of JCAHO's universal protocol for surgical and invasive procedures. The other choices are correct as they are essential components of the protocol to prevent wrong site, wrong person, and wrong procedure/surgery. A: Marking the operative site helps ensure the correct site is operated on. B: Conducting pre-procedure verification process ensures all necessary steps are taken before the procedure. D: Conducting a 'time out' immediately before starting the procedure allows the surgical team to confirm key details before proceeding.