A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect as it assumes the patient's fear is related to dressing changes, not discharge. Choice B is incorrect as resuming medications is not linked to the patient's fear of being alone. Choice D is incorrect as there is no indication in the scenario that the surgery was unsuccessful.

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. This is the correct answer because the patient's fear of going home and being alone indicates apprehension about discharge, which is a common feeling among patients transitioning from the hospital to home care. This subjective data suggests that the patient may need additional support and education prior to discharge to address their fears and concerns. A: The patient can now perform the dressing changes without help - This is incorrect because the patient's fear of going home and being alone does not necessarily indicate their ability to perform dressing changes independently. B: The patient can begin retaking all of the previous medications - This is incorrect as the fear expressed by the patient is related to being alone at home, not to medication management. D: The patient’s surgery was not successful - This is incorrect as there is no indication in the subjective data provided that the surgery was not successful.

Correct Answer: A

Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: C

Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.

Correct Answer: C

Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.