Aling Iska, a 78-year old client consults with a hemoglobin and hematocrit levels of 11mg/dl and 32 % respectively. These finding indicates:

Correct Answer: B

Rationale: Rationale: Answer B is correct because a hemoglobin level of 11mg/dl and hematocrit level of 32% in a 78-year-old client are indicative of anemia. Conducting a thorough nutritional assessment is essential to identify potential causes of anemia such as iron deficiency or vitamin deficiencies. This assessment will help determine appropriate interventions to manage the anemia. Summary: A: Incorrect. These levels are indicative of anemia, not normal findings. C: Incorrect. Advising to repeat the test in three months may delay necessary interventions for the anemia. D: Incorrect. While anemia can be related to bone marrow degeneration, a nutritional assessment is needed to identify the specific cause in this case.

Correct Answer: B

Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.

Correct Answer: B

Rationale: The correct answer is B: Lung cancer. It causes the most deaths in women because it is often diagnosed at advanced stages when treatment options are limited. Breast cancer, although common, has a higher survival rate. Brain cancer is relatively rare compared to lung cancer. Colon and rectal cancer, while prevalent, do not surpass lung cancer in terms of mortality rates in women.

Correct Answer: C

Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion. Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.

Correct Answer: C

Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term. Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues. Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels. Step 4: Emergency numbers are important but secondary to long-term management. Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.

Correct Answer: B

Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. The lab value of K at 3.2 mEq/L indicates hypokalemia. 2. Digitalis can worsen hypokalemia and lead to toxicity. 3. Avoiding foods rich in potassium will prevent further lowering of potassium levels. 4. This intervention helps prevent potential digitalis toxicity in the client. Summary of why the other choices are incorrect: A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition. B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values. D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.

Correct Answer: B

Rationale: The correct answer is B because asking about the frequency of bowel movements is crucial in assessing diarrhea, a common symptom. This information helps determine the severity and duration of the condition, guiding the nurse in identifying potential causes and appropriate interventions. Choice A focuses on the cause of upset stomach, not specifically diarrhea. Choice C is more related to incontinence rather than diarrhea. Choice D is important but not directly related to establishing a nursing diagnosis for diarrhea. Therefore, Choice B is the most appropriate question to assist in accurately assessing and diagnosing diarrhea.

Correct Answer: B

Rationale: The correct answer is B: Collect his urine for 12 hours. This instruction is given because the Schilling test involves collecting urine over a specific time period to measure the absorption of vitamin B12. A is incorrect because fasting is not necessary. C is incorrect as enema is not required. D is incorrect as emptying the bladder is not part of the test procedure.