A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient’s plan of care?

Correct Answer: B

Rationale: The correct answer is B because before discontinuing a patient's plan of care related to physical mobility, the nurse needs to evaluate whether the patient goals and outcomes have been met. This step ensures that the patient has achieved the desired level of physical mobility improvement and is ready to safely continue their care at home. A: Determining whether the patient has transportation to get home is important but not directly related to the patient's physical mobility goals and outcomes. C: Establishing a follow-up appointment is important but does not directly address the evaluation of the patient's physical mobility improvement. D: Ensuring that the patient's prescriptions are filled is crucial for medication management but does not specifically evaluate the patient's physical mobility progress.

Correct Answer: A

Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.

Correct Answer: B

Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.

Correct Answer: B

Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.