Correct Answer: A

Rationale: The correct answer is A: Facial tenderness. Sinus infections commonly present with facial tenderness due to the inflammation and pressure within the sinuses. This symptom is often accompanied by pain or pressure around the eyes, cheeks, and forehead. Photophobia (B) is more commonly associated with conditions like migraines or meningitis. Chest pain (C) is not a typical symptom of a sinus infection. Ear drainage (D) is more indicative of an ear infection rather than a sinus infection.

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. In this scenario, the nurse needs to analyze the data and identify the patient's problem, which is urinary retention due to abnormal kidney function and decreased oral intake. This step is crucial to develop a care plan. Planning (B) comes after diagnosis, where interventions are determined. Implementation (C) involves executing the care plan, and Evaluation (D) is the final step to assess the effectiveness of interventions.

Correct Answer: B

Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge. A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation. C: General assessments are broad and not targeted towards a specific issue like infection at an incision site. D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection. In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.

Correct Answer: A

Rationale: The correct answer is A because using the client's own words in quotation marks ensures accurate representation of their subjective data. It maintains the integrity of the information provided by the client and improves communication between healthcare providers. Paraphrasing (choice B) may lead to misinterpretation or distortion of the client's statements. Validating with the client's family (choice C) may introduce bias or inaccurate information. Recording with nonspecific words (choice D) decreases the clarity and specificity of the documentation, which is essential for effective communication and decision-making in healthcare.

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship. Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.