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: A

Rationale: The correct answer is A: A hemolytic reaction to mismatched blood. Chills, dyspnea, and urticaria are indicative of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks the donor's red blood cells. This can lead to various symptoms, including fever, chills, difficulty breathing, and hives. This type of reaction is most commonly seen with mismatched blood types. Option B (A hemolytic reaction to Rh-incompatible blood) is incorrect because Rh incompatibility typically leads to hemolytic disease of the newborn, not an immediate transfusion reaction. Option C (A hemolytic allergic reaction caused by bacterial contamination of donor blood) is incorrect as bacterial contamination would present with symptoms such as fever and sepsis, not chills, dyspnea, and urticaria. Option D (None of the above) is incorrect as the symptoms presented align with a hemolytic transfusion reaction.

Correct Answer: B

Rationale: The correct answer is B because it is important for the nurse to communicate directly with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter may undermine the patient's autonomy and dignity. It is crucial for the nurse to establish rapport and build a therapeutic relationship with the patient. Making eye contact with the patient (choice A) is a good nonverbal communication technique. Leaning forward while talking with the patient (choice C) shows attentiveness and engagement. Nodding periodically while the patient is speaking (choice D) demonstrates active listening and encourages the patient to continue sharing. However, speaking only to the patient's daughter (choice B) is the incorrect choice as it neglects the patient's role in the conversation and may lead to potential issues in communication and patient-centered care.

Correct Answer: C

Rationale: The correct answer is C: IgM. During an acute infection, the body's initial response is rapid and non-specific, leading to the production of IgM antibodies first. IgM is the first immunoglobulin class produced in response to a new antigen, providing immediate protection. IgG is produced later in the immune response and is responsible for long-term immunity. IgE is involved in allergic reactions and parasitic infections, not typically the first response to infection. IgD is primarily found on the surface of B cells and its function is not well understood in the context of acute infections.

Correct Answer: A

Rationale: The correct answer is A: Use parallel bars or a walker. Before a client with impaired physical mobility gets up, the nurse should provide assistive devices like parallel bars or a walker to ensure safe and supported ambulation. This helps prevent falls and promotes independence. Using incontinence pads (B) is not directly related to mobility. Applying an abdominal binder (C) is not necessary before the client gets up. Using a footboard (D) is more relevant for positioning in bed, not for assisting with ambulation.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.

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 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 because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.