A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?

Correct Answer: B

Rationale: The correct answer is B: Health behavior. Evaluating the patient's demonstration of self-injection assesses their ability to perform a specific health-related action. This choice focuses on the patient's actions and behaviors related to their health, aligning with the scenario provided. Choice A: Health status is incorrect because it refers to the patient's current physical condition, not their ability to perform a specific health action. Choice C: Psychological self-control is incorrect as it pertains to the patient's ability to regulate their emotions and impulses, not their ability to self-administer injections. Choice D: Health service utilization is incorrect as it relates to the frequency and pattern of healthcare services used by the patient, not their ability to perform a specific health behavior.

Correct Answer: A

Rationale: The correct answer is A: 11mEq/L. In renal failure, the kidneys are unable to excrete excess magnesium, leading to hypermagnesemia. The patient's symptoms of stomach distress and ingesting antacids suggest magnesium intake. A Mg level of 11mEq/L aligns with symptoms like flushed face and weakness. Choices B, C, and D are too low for hypermagnesemia symptoms and would not explain the patient's presentation.

Correct Answer: C

Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.

Correct Answer: C

Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions. Incorrect choices: A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment. B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management. D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.

Correct Answer: D

Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion can occur from trauma or surgery, while infections from other organs like the lungs or heart can travel through the bloodstream to the brain. Infections from nearby sites such as the sinuses or ears can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C alone do not encompass all the possible causes of a brain abscess, making D the correct comprehensive answer.

Correct Answer: D

Rationale: The correct answer is D: Vitamin D. Vitamin D is essential for the absorption of calcium in the intestines. Without sufficient vitamin D, the body cannot effectively absorb calcium, leading to potential issues with calcium absorption. Vitamin A (choice A) is not directly involved in calcium absorption. Vitamin B (choice B) and Vitamin C (choice C) also do not play a significant role in calcium absorption. Therefore, the lack of Vitamin D is the most likely cause for problems with calcium absorption.

Correct Answer: D

Rationale: The correct answer is D: A bleeding disorder. Thoracentesis involves inserting a needle into the pleural space to remove fluid. A bleeding disorder increases the risk of excessive bleeding during the procedure. This can lead to complications such as hematoma formation, pneumothorax, or even life-threatening bleeding. It is crucial to assess and address bleeding disorders before performing thoracentesis to ensure the safety of the client. A: A seizure disorder is not a contraindication for thoracentesis unless uncontrolled seizures could compromise the safety of the procedure. B: Anemia alone is not a contraindication for thoracentesis, as it does not directly increase the risk of complications during the procedure. C: Chronic obstructive pulmonary disease is not a contraindication for thoracentesis unless it is severe and compromises the client's ability to tolerate the procedure.

Correct Answer: A

Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.

Correct Answer: A

Rationale: The correct answer is A: Include potassium-rich foods. Diuretics can cause potassium loss, leading to hypokalemia. Including potassium-rich foods helps prevent this deficiency. Choice B is incorrect because fruits and fruit juices are often good sources of potassium. Choice C is incorrect as protein-rich foods do not specifically address potassium needs. Choice D is incorrect as dairy products are also good sources of potassium. Therefore, recommending potassium-rich foods is essential to prevent hypokalemia in clients taking diuretics.