A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Correct Answer: C

Rationale: The correct answer is C: Health promotion. This type of diagnosis focuses on improving the client's well-being and maximizing their health potential. By adding Readiness for enhanced urinary elimination to the care plan, the nurse acknowledges the patient's willingness to learn self-catheterization, which aligns with health promotion. Other choices are incorrect because: A (Risk) implies potential harm, B (Problem focused) focuses on current issues, and D (Collaborative problem) involves multiple healthcare providers working together on a specific problem.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis of Readiness for enhanced urinary elimination, which indicates the patient's willingness to improve their urinary elimination abilities. Health promotion diagnoses focus on improving the client's well-being and enhancing their health potential. In this scenario, the patient's desire to learn self-catheterization aligns with health promotion as it involves empowering the patient to take an active role in their care. Choice A (Risk) is incorrect because the patient is not currently at risk for urinary elimination issues, but rather seeking to enhance their abilities. Choice B (Problem focused) is incorrect as the diagnosis is not about addressing a current problem but rather focusing on potential improvement. Choice D (Collaborative problem) is incorrect as it does not involve collaboration between healthcare providers but rather focuses on the patient's readiness and willingness to enhance their own health outcomes.

Correct Answer: B

Rationale: The correct answer is B: Apply insect repellent to clothing and exposed skin. This advice helps prevent insect bites, reducing the risk of recurrence. Insect repellent creates a barrier against insects, hence minimizing the chances of getting bitten. Other choices are incorrect as they do not directly address the prevention of insect bites. Choice A is vague and does not provide a specific preventive measure. Choice C is incorrect as thick woollen clothing may not necessarily prevent insect bites. Choice D, sunscreen lotion, protects against UV rays, not insect bites.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: 1. Asking about chief concerns helps to focus the interview on the patient's needs. 2. It demonstrates active listening and empathy. 3. Allows the nurse to prioritize issues and provide appropriate care. 4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.

Correct Answer: D

Rationale: Step 1: Levothyroxine (Synthroid) is the synthetic form of the thyroid hormone T4, the main hormone produced by the thyroid gland. Step 2: Levothyroxine is the preferred agent for thyroid hormone replacement therapy in hypothyroidism due to its stable and consistent potency. Step 3: Levothyroxine is well-absorbed by the body and has a long half-life, allowing for once-daily dosing. Step 4: Other choices are incorrect because Methimazole is used to treat hyperthyroidism, Livothyronine is a form of T3 hormone not commonly used for replacement therapy, and Thyroid USP dessicated is derived from animal thyroid glands and has inconsistent hormone content. Summary: Levothyroxine (Synthroid) is the preferred choice for thyroid hormone replacement therapy due to its synthetic nature, stable potency, good absorption, and long half-life. Other options are not

Correct Answer: D

Rationale: The correct answer is D: Subclavian veins. Lymph returns to the blood through the subclavian veins because they receive lymphatic drainage from the thoracic duct and right lymphatic duct. Lymphatic vessels merge into lymphatic ducts, which empty into the subclavian veins, allowing lymph to re-enter the bloodstream. The carotid arteries (A) carry oxygen-rich blood to the brain, the aorta (C) is the main artery of the body carrying oxygenated blood from the heart, and the inferior vena cava (B) returns deoxygenated blood from the lower body to the heart. Therefore, choices A, B, and C are incorrect as they are not involved in the return of lymph to the blood.

Correct Answer: B

Rationale: The correct answer is B because before discontinuing a patient's plan of care related to physical mobility, the nurse needs to evaluate whether the patient goals and outcomes have been met. This step ensures that the patient has achieved the desired level of physical mobility improvement and is ready to safely continue their care at home. A: Determining whether the patient has transportation to get home is important but not directly related to the patient's physical mobility goals and outcomes. C: Establishing a follow-up appointment is important but does not directly address the evaluation of the patient's physical mobility improvement. D: Ensuring that the patient's prescriptions are filled is crucial for medication management but does not specifically evaluate the patient's physical mobility progress.

Correct Answer: D

Rationale: The correct answer is D: "I will have my potassium level checked." Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. A: Monitoring urine sodium is not typically necessary for furosemide therapy. B: Prothrombin time monitoring is unrelated to furosemide therapy. C: Monitoring calcium levels is not directly affected by furosemide use. In summary, monitoring potassium levels is essential due to the potential for hypokalemia with furosemide, while the other options are not directly relevant to this medication.

Correct Answer: C

Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation. Incorrect Choices: A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection. B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection. D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.