A nurse is documenting the progress of a client who has been recovering from a myocardial infarction. Which of the following would be most appropriate to include in the evaluation?

Correct Answer: B

Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.

Correct Answer: A

Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.

Correct Answer: C

Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and potentially disrespectful attitude towards the nurse. This response does not promote a collaborative and respectful communication between the daughter and the nurse. In a healthcare setting, it is important for family members to communicate effectively and respectfully with the healthcare team to ensure the best care for the patient. A: This statement shows understanding and acceptance of the symptoms of the disease, indicating good knowledge. C: This statement shows willingness to help the patient with tasks he cannot do for himself, which is a positive and caring attitude. D: This statement shows consideration for the patient's needs by planning to turn off the TV when moving to another room, which is appropriate.

Correct Answer: D

Rationale: The correct answer is D: Increased calcium level. Parathyroid hormone functions to increase blood calcium levels. When calcium levels are low, the parathyroid gland releases PTH to stimulate the release of calcium from bones and increase calcium absorption from the intestines and kidneys. This helps to maintain normal calcium levels in the blood. Choices A, B, and C are incorrect because decreased phosphate level, functioning thyroid gland, and adequate vitamin D level are not direct requirements for the action of parathyroid hormone.

Correct Answer: C

Rationale: The correct answer is C: Memory cells. After recovery from a disease, memory cells are formed as part of the adaptive immune response. These memory cells "remember" the pathogen and can mount a quicker and stronger immune response upon re-exposure. This results in immunity to the disease. Antigens (choice A) are substances that trigger the immune response but do not provide immunity on their own. Complement (choice B) is a group of proteins that enhance the immune response but do not directly lead to immunity. Natural killer cells (choice D) are part of the innate immune system and are not responsible for the specific memory response needed for immunity.

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.

Correct Answer: C

Rationale: The correct answer is C: Vitamin D. In hypoparathyroidism, there is a deficiency of parathyroid hormone leading to low calcium levels. Vitamin D helps in the absorption of calcium from the intestines, thus aiding in maintaining normal calcium levels. It is often prescribed along with calcium supplements to support bone health and prevent complications. Folic acid (A) is not directly related to the treatment of hypoparathyroidism. Potassium (B) is not typically prescribed for this condition and can be harmful in high levels. Iron (D) is not directly involved in calcium metabolism and is not part of the standard treatment regimen for hypoparathyroidism.

Correct Answer: C

Rationale: The correct answer is C: Surgical removal. Surgical removal of the cancerous tumor is the best treatment before metastasis because it physically removes the cancer cells. Chemotherapy and radiation are used to treat cancer after it has spread, not as the primary treatment. Choice D is incorrect because not all types of cancer can be effectively treated with all three options.