A nurse is performing an assessment on a patientwho has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?

Correct Answer: A

Rationale: The correct answer is A: Hypoactive bowel sounds. When a patient has not had a bowel movement in 3 days, it indicates constipation. Constipation can lead to decreased peristalsis, resulting in hypoactive bowel sounds. Increased fluid intake (B) would be a potential intervention, not an expected assessment finding. A soft tender abdomen (C) may indicate other issues like inflammation or infection, not directly related to constipation. Jaundice in the sclera (D) is indicative of liver dysfunction, not a typical finding associated with constipation.

Correct Answer: D

Rationale: The correct answer is D: Reduce disparities. In equity-focused quality improvement, the primary goal is to address and reduce disparities in healthcare outcomes and access. By focusing on reducing disparities, the hospital ensures that all patients receive equitable care regardless of their background. Documenting staff satisfaction (A) is important but not directly related to equity-focused improvement. Focusing on the family (B) is essential for patient-centered care but doesn't specifically address equity. Implementing change on a grand scale (C) may not necessarily target disparities directly. Therefore, reducing disparities aligns best with equity-focused quality improvement principles.

Correct Answer: D

Rationale: The correct answer is D, combining multiple objective measures with subjective measures. This approach provides a comprehensive assessment of the patient's nutritional status by incorporating both quantitative data (objective measures) such as weight, BMI, and laboratory values, as well as qualitative information (subjective measures) like dietary history and appetite changes. By combining these measures, the nurse can obtain a more holistic view of the patient's nutritional status, allowing for better identification of nutritional deficiencies or excesses. This method enhances the accuracy and reliability of the assessment compared to relying solely on one type of measure. Choice A is incorrect because nutritional assessment is crucial even in the presence of chronic disease to address potential malnutrition risks. Choice B is incorrect as the Mini Nutritional Assessment is not intended for pediatric patients but for adults. Choice C is incorrect as using a single tool may not capture the full complexity of the patient's nutritional status.

Correct Answer: B

Rationale: The correct answer is B: Circumcision. Paraphimosis occurs when the foreskin is retracted behind the glans and cannot be returned to its original position. Once the inflammation and edema subside, circumcision is typically indicated to prevent recurrence. This procedure removes the foreskin, reducing the risk of future paraphimosis episodes. Needle aspiration of the corpus cavernosum (A) is not indicated for paraphimosis. Abstinence from sexual activity for 6 weeks (C) is not a standard treatment for paraphimosis. Administration of vardenafil (D) is used for erectile dysfunction and not indicated for paraphimosis.

Correct Answer: C

Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate and comprehensive response to the pregnant patient's question about the risk of her baby being born with HIV. Here's the step-by-step rationale: 1. Option D acknowledges the possibility of the baby contracting HIV at different stages: before, during, or after delivery. This covers all potential scenarios and educates the patient about the risks. 2. By mentioning the different possible transmission times, the nurse highlights the importance of proper prenatal care, delivery planning, and postnatal care to minimize the risk of HIV transmission to the baby. 3. This response empowers the patient with knowledge about the potential risks and emphasizes the importance of seeking appropriate medical interventions to prevent mother-to-child transmission of HIV. 4. In contrast, options A, B, and C provide less informative or inaccurate responses that do not address the patient's concerns adequately, making them incorrect choices. In summary, option D is the best response as it educates the patient about the risks of HIV transmission

Correct Answer: C

Rationale: The correct answer is C: Lobules and ducts. Each lobe of the breast consists of lobules, which are responsible for milk production, and ducts, which transport the milk to the nipple. This is essential for breastfeeding. Modified tendons and ligaments (choice A) are not present in the lobes of the breast. Connective tissue and smooth muscle (choice B) are important components of the breast but do not specifically make up the lobes. Endocrine glands and sebaceous glands (choice D) are not the primary elements within the lobes of the breast responsible for milk production and transport. The lobules and ducts are vital components for the functioning of the breast in lactation.

Correct Answer: A

Rationale: The correct answer is A: Ask if he would like you to sit with him while he collects his thoughts. Rationale: 1. Active listening: By offering to sit with him, you show empathy and support his emotional expression. 2. Respect his autonomy: Asking if he would like you to sit allows him to make a choice about what support he needs. 3. Nonjudgmental approach: Sitting with him creates a safe space for him to share his feelings without feeling rushed or judged. Summary: B: Leaving abruptly may make him feel abandoned in a vulnerable moment. C: While spiritual support can be beneficial, it may not address his immediate emotional needs. D: Reassurance is important but may not be as effective as actively listening and offering support in this context.

Correct Answer: B

Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.