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: bacteria. Hepatitis is primarily caused by viruses (such as Hepatitis A, B, C), toxins (like alcohol or certain medications), and chemicals/drugs. Bacteria do not typically cause hepatitis as it is a viral infection that affects the liver. Therefore, choice C is the exception among the listed causes. Viruses directly target liver cells, toxins can damage the liver, and certain chemicals/drugs can lead to liver inflammation. Hence, bacteria do not play a significant role in causing hepatitis.

Correct Answer: C

Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.

Correct Answer: B

Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention. Choices A, C, and D are incorrect: A: Palpating the elbow could exacerbate the bleeding and cause further damage. C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding. D: Applying heat can increase blood flow to the joint, worsening the bleeding.

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.