A patient reports severe abdominal pain. The nurse begins with:

Correct Answer: C

Rationale: The correct answer is C: Inspection to note visible abnormalities. Inspection is the initial assessment technique used to observe visible signs such as distention, discoloration, or scars. This helps in gathering important information about the patient's condition before proceeding to palpation or percussion. Light palpation (choice A) and deep palpation (choice B) involve touching the abdomen, which may worsen the pain or miss important visual clues. Percussion (choice D) is typically used after inspection and palpation to assess organ density, not as the initial step in assessing abdominal pain.

Correct Answer: D

Rationale: The correct answer is D because brownish discoloration to the skin of the lower leg is a classic sign of venous stasis due to hemosiderin deposition from chronic venous insufficiency. This occurs as a result of red blood cell breakdown and leaking into the tissues. The other choices are incorrect because: A) Unilateral cool foot is more indicative of arterial insufficiency, B) Thin, shiny, atrophic skin is characteristic of arterial insufficiency or aging, and C) Pallor of the toes and cyanosis of the nail beds are signs of arterial insufficiency as well.

Correct Answer: C

Rationale: The correct sequence (C) starts with greeting the patient to establish rapport, then inviting the patient's story to understand their perspective. Next, establishing the agenda ensures all concerns are addressed. Expanding and clarifying the patient's story allows for a comprehensive assessment. Finally, negotiating a plan involves collaborative decision-making. Option A is incorrect because establishing rapport is essential before setting the agenda. Option B is incorrect as inviting the patient's story should come before negotiating a plan. Option D is incorrect as negotiating a plan should be the final step after understanding the patient's story.

Correct Answer: B

Rationale: The correct answer is B: Flight of ideas. Flight of ideas is a symptom commonly seen in manic episodes, where thoughts are rapidly moving from one idea to another, making it challenging to follow the conversation. In this scenario, the patient's fast and erratic speech pattern with disjointed ideas aligns with the classic presentation of flight of ideas. Derailment (A) refers to a sudden shift in the topic without any apparent connection, which is not the case here. Circumstantiality (C) involves providing unnecessary detail before reaching the main point, which does not fit the description provided. Incoherence (D) refers to speech that is illogical and incomprehensible, which is not the primary feature presented in the scenario.

Correct Answer: A

Rationale: The correct answer is A because evidence-based nursing practice involves combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances. This approach ensures that nursing interventions are based on the best available evidence, tailored to individual patient needs, and aligned with patient preferences. It emphasizes the integration of research evidence, clinical expertise, and patient values to optimize patient outcomes. Choice B is incorrect because evidence-based nursing practice involves a comprehensive review of multiple research studies, not just one or two articles. Choice C is incorrect because completing a literature search is just one step in the evidence-based practice process, which also involves critically appraising and applying the evidence to patient care. Choice D is incorrect because evidence-based practice focuses on using research evidence, not value-based resources, to guide nursing actions.