A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?

Correct Answer: C

Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.

Correct Answer: C

Rationale: Cisplatin is a cornerstone in the treatment of germ cell tumors.

Correct Answer: B

Rationale: Spastic cerebral palsy is the most common type.

Correct Answer: C

Rationale: Regular follow-up care is crucial after a thyroidectomy for Grave's disease to monitor the patient's thyroid hormone levels, assess for signs of complications such as hypothyroidism or hypoparathyroidism, and ensure appropriate management of any related conditions. Routine follow-up visits with healthcare providers allow for ongoing assessment and adjustment of medications, as well as addressing any concerns the patient may have post-surgery. By emphasizing the importance of regular follow-up care, the healthcare team can provide necessary support and guidance to the patient throughout their recovery process.

Correct Answer: C

Rationale: The presence of fluid in both lung bases, as indicated by the chest x-ray examination, suggests the possibility of pulmonary congestion or fluid accumulation in the lungs. Bilateral crackles, also known as rales, are a common clinical finding associated with pulmonary edema. Crackles are discontinuous, brief, popping sounds heard on auscultation of the lungs. These adventitious breath sounds occur when air passes through fluid in the small airways or alveoli. Therefore, the presence of bilateral crackles during the nurse's assessment would most reflect the x-ray examination findings of fluid in both lung bases. Fatigue, peripheral edema, and jugular vein distention may also be present in conditions involving fluid overload, such as heart failure, but bilateral crackles specifically point to the presence of fluid in the lungs.