A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? NursingStoreRN

Correct Answer: D

Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.

Correct Answer: A

Rationale: The correct answer is A: Confusion or delirium can be a defense against further stress. This is because providing new information slowly and in small amounts can help prevent overwhelming Mr. Reyes, who is already confused. This approach allows him to process and understand the information more effectively without adding to his stress levels. Choices B, C, and D are incorrect: B: Destruction of brain cells has occurred, interrupting mental activity - This is not the most appropriate explanation as it assumes irreversible damage to the brain, which is not mentioned in the question. C: Teaching based on information progressing from the simple to the complex - While this may be a valid teaching strategy in general, it does not address Mr. Reyes' specific state of confusion and the need to reduce stress. D: A minimum of information should be given, since he is unaware of surrounding - This choice does not address the underlying reason for providing information slowly, which is to manage stress and confusion, rather than solely focusing on the

Correct Answer: C

Rationale: The correct answer is C: IgM. During an acute infection, the body's initial response is rapid and non-specific, leading to the production of IgM antibodies first. IgM is the first immunoglobulin class produced in response to a new antigen, providing immediate protection. IgG is produced later in the immune response and is responsible for long-term immunity. IgE is involved in allergic reactions and parasitic infections, not typically the first response to infection. IgD is primarily found on the surface of B cells and its function is not well understood in the context of acute infections.

Correct Answer: D

Rationale: The correct answer is D: Doing it according to his needs and abilities. This option is the most appropriate intervention for Mang Simon to maintain his exercise program. By tailoring the program to his needs and abilities, Mang Simon is more likely to adhere to it and prevent any potential injuries or health risks associated with overexertion. This approach ensures that the exercise routine is realistic and manageable for him, increasing his chances of long-term success. A: Writing down the exercise program may be helpful for organization but does not address the individualization needed for Mang Simon's specific situation. B: Thoroughly explaining the program to his wife, Aling Nena, may provide support but does not directly impact Mang Simon's ability to maintain the program. C: Positive motivation is important, but it alone may not be sufficient to address the practical aspects of adapting the exercise program to Mang Simon's needs and abilities.

Correct Answer: B

Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.

Correct Answer: D

Rationale: Step-by-step rationale for choosing answer D as correct: 1. Acknowledges patient's withdrawn behavior 2. Demonstrates empathy and concern 3. Open-ended question allows patient to express feelings 4. Encourages patient to communicate concerns Summary: - Option A assumes a specific problem without patient input - Option B focuses on verbalization, not necessarily addressing underlying concerns - Option C makes assumptions about patient's worries without allowing him to express himself

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. The lab value of K at 3.2 mEq/L indicates hypokalemia. 2. Digitalis can worsen hypokalemia and lead to toxicity. 3. Avoiding foods rich in potassium will prevent further lowering of potassium levels. 4. This intervention helps prevent potential digitalis toxicity in the client. Summary of why the other choices are incorrect: A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition. B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values. D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Include dressing change instructions and frequency in the care plan. This is the correct action because it ensures consistency in care and communication among the nursing team. By documenting the dressing change instructions and frequency in the care plan, all nurses will have clear guidance on how to perform the dressing changes correctly and at the appropriate intervals. This promotes continuity of care and helps prevent errors or omissions in the dressing change process. Option B is incorrect as it is not realistic to expect the wound nurse to perform all dressing changes. Option C is unnecessary unless there are specific concerns requiring the health care provider's attention. Option D is not appropriate as encouraging the patient to perform dressing changes may not be safe or feasible depending on the patient's condition.

Correct Answer: A

Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function. Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.