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 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: D

Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.

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: A

Rationale: The correct answer is A because continuous assessment allows for timely identification of changes in the client's condition. This is crucial for providing appropriate and timely interventions. Assessing the client only at specific times (choices B and C) may lead to missing important changes. Choice D is incorrect because assessments should not be limited to physician rounds; they should be ongoing to ensure comprehensive care.

Correct Answer: C

Rationale: The correct answer is C because it is a realistic goal for a patient with a pelvic fracture on bed rest. The patient needs to use a walker correctly to ambulate safely to the bathroom, which promotes mobility and independence while ensuring safety. This goal is specific, measurable, achievable, relevant, and time-bound. Choice A is incorrect because increasing activity level may not be safe or feasible for a patient with a pelvic fracture. Choice B is incorrect as turning every 2 hours may not be necessary or practical for this patient. Choice D is incorrect as using a sliding board may not be appropriate or necessary for someone with a pelvic fracture.

Correct Answer: C

Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.

Correct Answer: B

Rationale: Step-by-step rationale: 1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception. 2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal. 3. Hypotension (choice A) is not directly related to the Romberg test. 4. Sneezing and wheezing (choice C) are unrelated to the test. 5. Excessive cerumen in the outer ear (choice D) does not affect proprioception. Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.

Correct Answer: B

Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.

Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening is crucial when working with a dying client and their family as it involves fully concentrating, understanding, responding, and remembering what is being said. This technique helps the nurse show empathy, build trust, and provide emotional support. By actively listening, the nurse can better understand the client's needs and concerns, which is essential in end-of-life care. Reflection (A) involves paraphrasing what the client said, which may not always be appropriate in this sensitive situation. Clarification (B) and Interpretation (C) involve adding one's own understanding or perspective, which can be intrusive and may not align with the client's feelings or beliefs.