A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe. 2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention. 3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue. 4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking. Summary: - Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking. - Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database. - Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation. - Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.

Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

Correct Answer: A

Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.

Correct Answer: A

Rationale: Step 1: Involving the client in planning increases their understanding and ownership of the plan. Step 2: Understanding leads to better compliance with therapy recommendations. Step 3: Compliance improves outcomes and prevents complications. Step 4: Thus, choice A is correct. Choices B, C, and D lack direct links to client involvement in planning and compliance.