A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Correct Answer: C

Rationale: The correct answer is C because it is a realistic goal for a patient with a pelvic fracture on bed rest. The patient needs to use a walker correctly to ambulate safely to the bathroom, which promotes mobility and independence while ensuring safety. This goal is specific, measurable, achievable, relevant, and time-bound. Choice A is incorrect because increasing activity level may not be safe or feasible for a patient with a pelvic fracture. Choice B is incorrect as turning every 2 hours may not be necessary or practical for this patient. Choice D is incorrect as using a sliding board may not be appropriate or necessary for someone with a pelvic fracture.

Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening is crucial when working with a dying client and their family as it involves fully concentrating, understanding, responding, and remembering what is being said. This technique helps the nurse show empathy, build trust, and provide emotional support. By actively listening, the nurse can better understand the client's needs and concerns, which is essential in end-of-life care. Reflection (A) involves paraphrasing what the client said, which may not always be appropriate in this sensitive situation. Clarification (B) and Interpretation (C) involve adding one's own understanding or perspective, which can be intrusive and may not align with the client's feelings or beliefs.

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. This is the correct answer because the patient's fear of going home and being alone indicates apprehension about discharge, which is a common feeling among patients transitioning from the hospital to home care. This subjective data suggests that the patient may need additional support and education prior to discharge to address their fears and concerns. A: The patient can now perform the dressing changes without help - This is incorrect because the patient's fear of going home and being alone does not necessarily indicate their ability to perform dressing changes independently. B: The patient can begin retaking all of the previous medications - This is incorrect as the fear expressed by the patient is related to being alone at home, not to medication management. D: The patient’s surgery was not successful - This is incorrect as there is no indication in the subjective data provided that the surgery was not successful.

Correct Answer: D

Rationale: The correct answer is D: vasopressin (Pitressin). In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), which leads to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps regulate water balance by reducing urine output. Therefore, administering vasopressin would help manage the symptoms of diabetes insipidus. Insulin (A) is used for diabetes mellitus, not diabetes insipidus. Potassium chloride (B) is used to correct potassium imbalances, not specific to diabetes insipidus. Furosemide (Lasix) (C) is a diuretic that increases urine output, which would worsen the symptoms of diabetes insipidus.

Correct Answer: C

Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms. Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.

Correct Answer: A

Rationale: The correct answer is A: Nystagmus. A phenytoin blood level of 35 mcg/ml is above the therapeutic range (usually 10-20 mcg/ml). Excessive levels can lead to symptoms such as nystagmus, which is an involuntary eye movement commonly seen with phenytoin toxicity. Nystagmus is a known side effect of phenytoin overdose. Choices B and C are incorrect because a level of 35 mcg/ml is not within the normal therapeutic range, so symptoms would be expected. Choice D, Slurred speech, is not typically associated with phenytoin toxicity.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.

Correct Answer: C

Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.

Correct Answer: B

Rationale: The correct answer is B because tension headaches typically present as a feeling of pressure or steady constriction on both sides of the head. This is due to muscle tension in the head and neck. Choice A is incorrect as sensitivity to light is more characteristic of migraines. Choice C is incorrect as unilateral paralysis is not typically associated with tension headaches. Choice D is incorrect as vague headache especially peri orbital is not a common symptom of tension headaches. Therefore, the best description of discomfort experienced by a client with a tension headache is the pressure or steady constriction on both sides of the head.