A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

Correct Answer: C

Rationale: The correct answer is C: Acute pain. The patient's right femur fracture would likely cause significant pain. Treating the pain is a priority to ensure the patient's comfort and promote healing. Posttrauma syndrome (A) is more applicable for patients experiencing emotional distress following a traumatic event. Constipation (B) may be a concern due to immobility but is not as immediate as managing pain. Anxiety (D) may be present but addressing the acute pain would likely alleviate some anxiety as well.

Correct Answer: B

Rationale: The correct answer is B: Abnormal sensations such as burning and numbness. In AIDS-related DSP, damage to nerves causes abnormal sensations like burning and numbness. This is due to the progressive nerve damage affecting sensory functions. Staggering gait and muscle incoordination (A) are more common in conditions affecting motor nerves. Delusional thinking (C) is not a symptom of DSP. Incontinence (D) is not typically associated with DSP but may happen in more advanced stages due to loss of sensation.

Correct Answer: A

Rationale: Correct Answer: A (Independent intervention) Rationale: 1. Independent interventions are actions that nurses can initiate without a doctor's order. 2. Teaching a client how to administer insulin falls under the scope of nursing practice. 3. Nurses have the knowledge and authority to educate clients on self-care management. 4. This intervention does not require collaboration with other healthcare providers. Summary: B: Dependent interventions require a doctor's order. C: Interdependent interventions involve collaboration with other healthcare providers. D: Collaborative interventions involve working with other healthcare professionals.

Correct Answer: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.

Correct Answer: A

Rationale: The correct answer is A because green leafy vegetables and soybeans are high in Vitamin K, which counteracts the anticoagulant effect of warfarin. Warfarin works by inhibiting Vitamin K-dependent clotting factors in the liver. By consuming Vitamin K-rich foods, the medication's effectiveness is reduced, leading to an increased risk of blood clot formation. Choices B, C, and D are incorrect because they do not address the specific interaction between Vitamin K and warfarin in affecting coagulation. Choice B suggests the opposite effect of what actually occurs. Choices C and D are irrelevant to the pharmacological mechanism of warfarin.

Correct Answer: B

Rationale: The correct answer is B: Discuss the negative feelings with the client. This is the most appropriate action as it allows the nurse to address and manage their own biases and attitudes towards the client in a professional and constructive manner. By acknowledging and discussing these feelings with the client, the nurse can work towards providing non-judgmental care and fostering a therapeutic relationship. A: Sharing these feelings with the client is not appropriate as it can harm the nurse-client relationship and potentially lead to discrimination. C: Developing a written interview form is not addressing the immediate issue of the nurse's negative attitude towards the client. D: Avoiding eye contact with the client is unprofessional and does not address the underlying issue of the nurse's negative feelings.

Correct Answer: C

Rationale: The correct answer is C - the circulating and scrub nurse first assistant. The circulating nurse is responsible for counting needles, sponges, and instruments during the closing of the surgical incision to ensure nothing is left inside the patient. The scrub nurse first assistant also plays a crucial role in this process by assisting in the counting and keeping track of the items used during the procedure. The other choices are incorrect because the surgeon and anesthesiologist (A) are not typically involved in counting items during the surgical closure, the surgeon and the registered (B) may not have the necessary training for accurate counting, and the anesthesiologist and anesthetist (D) are not directly involved in the surgical closing process.

Correct Answer: A

Rationale: The correct answer is A: Rice and lean chicken. A low residue diet aims to reduce fiber intake to ease digestion. Rice and lean chicken are low in fiber and easy to digest. Pasta with vegetables (B) contains high-fiber vegetables. Strawberry pie (C) is high in fiber due to fruit and crust. Tuna casserole (D) may contain high-fiber ingredients like noodles and vegetables. Therefore, A is the best choice for a low residue diet.

Correct Answer: B

Rationale: The correct answer is B: Protein. Antibodies are a type of protein produced by the immune system to help identify and neutralize pathogens like bacteria and viruses. Proteins are composed of amino acids, which are the building blocks of proteins. Antibodies have a specific structure that allows them to bind to specific antigens. Fat (A), Sugar (C), and Carbohydrates (D) are not primary components of antibodies and do not play a significant role in their structure or function.