After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

Correct Answer: A

Rationale: The correct answer is A: objective. Objective data refers to measurable and observable information obtained through physical examination or diagnostic tests. In this case, the nurse's documentation of the patient's respirations and pulse rate are objective data as they can be quantified and verified by any healthcare professional. This data is not influenced by personal feelings or interpretations, making it objective. Choice B, reflective, is incorrect as it does not describe the nature of the data provided. Choice C, subjective, is also incorrect because subjective data is based on the patient's feelings or perceptions, which is not the case here. Choice D, introspective, is incorrect as it refers to internal self-reflection, not the nature of the data being documented.

Correct Answer: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: C

Rationale: The correct answer is C: Using biased or leading questions. This question is biased and leading because it assumes that the patients attending the workshop do not engage in smoking, drinking, or drug use. It may influence the patients to provide inaccurate information if they feel pressured to conform to societal expectations. In health assessments, it is important to ask open-ended, non-judgmental questions to gather accurate and comprehensive information. Incorrect choices: A: Talking too much - This choice is not relevant to the question as it does not address the issue of biased or leading questions. B: Using confrontation - This choice does not apply as the question does not involve confronting the patients. D: Using blunt language to deal with distasteful topics - While the question may be blunt, the main issue is the bias and leading nature of the question, not its bluntness.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. Dehydration and hypotension indicate fluid loss, which can lead to organ damage and shock. Administering IV fluids helps restore blood volume and improve blood pressure. Monitoring blood pressure (B) is important but addressing the underlying issue of fluid loss is crucial. Administering antihypertensive medications (C) would further lower blood pressure, worsening hypotension. Administering diuretics (D) would exacerbate fluid loss, worsening dehydration and hypotension.

Correct Answer: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

Correct Answer: D

Rationale: The correct answer is D because an episodic history is most appropriate for acute, short-term conditions like cold and flu symptoms seen in an outpatient clinic. This type of history focuses on the current problem and recent events leading up to it. Choice A involves a long-term care facility, which would require a more comprehensive history. Choice B describes a sudden severe symptom, which would prompt an urgent or emergent history. Choice C involves an upcoming surgical procedure, which would require a preoperative history. Therefore, option D is the most appropriate for an episodic history as it aligns with the acute nature of the condition and the focus on the current issue.

Correct Answer: A

Rationale: The correct answer is A. Assessing serum creatinine levels and GFR is crucial in monitoring kidney function in CKD patients. These tests provide information on the kidney's ability to filter waste products from the blood. Monitoring these levels helps in determining the stage of CKD and adjusting treatment plans accordingly. Blood glucose levels (B) are important in diabetes management but not the priority in CKD. Hemoglobin levels (C) are important for anemia assessment in CKD but not as critical as kidney function. Potassium levels (D) are important to monitor in CKD, but assessing kidney function takes precedence.