As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.

Correct Answer: C

Rationale: The correct answer is C: “Are you feeling frightened? I’m here and I will help you.” This response acknowledges the resident’s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust. Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.

Correct Answer: A

Rationale: The correct answer is A: Applying the liquid test antigen. During a scratch test to detect allergies, the nurse's role is to apply the liquid test antigen onto the skin to observe the body's reaction. This antigen contains potential allergens that may trigger a response in allergic individuals. By applying this antigen, the nurse can assess if the patient develops a raised wheal or redness at the site, indicating an allergic reaction. This step is crucial in identifying specific allergens causing the patient's symptoms. Choices B, C, and D are incorrect as determining the type of allergy, measuring the length and width of the reaction, and documenting the findings are all important steps but do not directly relate to the initial action of applying the test antigen during a scratch test.

Correct Answer: B

Rationale: The correct answer is B: with coercion. Informed consent must be freely given without any form of coercion to ensure the individual's autonomy and decision-making capacity. Coercion can lead to involuntary consent, undermining the principle of respect for autonomy. Choices A, C, and D are all criteria for valid informed consent. Choice A ensures the individual is voluntarily agreeing without any external pressure. Choice C ensures the individual understands the procedures involved, promoting transparency. Choice D ensures the individual is aware of alternative options, allowing for an informed decision-making process.

Correct Answer: C

Rationale: The correct answer is C: Reassess the patient's pain level in 30 minutes. This is the priority action as it allows the nurse to evaluate the effectiveness of the acetaminophen in relieving the patient's headache. By reassessing the pain level, the nurse can determine if the medication is working or if further intervention is needed. A: Eliminating the headache from the care plan is not appropriate as the patient's comfort and pain relief should be a priority. B: Directing the nursing assistive personnel to inquire if the headache is relieved is not thorough assessment and does not provide direct evaluation of the patient's pain level. D: Revising the plan of care may be necessary based on the reassessment, but it is not the immediate priority compared to evaluating the patient's response to treatment.

Correct Answer: D

Rationale: The correct answer is D because hypertension is primarily determined by peripheral vascular resistance, which refers to the resistance in the blood vessels that the heart must overcome to pump blood effectively. This is a key factor in the development of high blood pressure. Choice A is incorrect as it simplifies the concept to just the pumping action of the heart. Choice B is incorrect because hypertension is not just about having high readings on separate occasions but rather a sustained elevation in blood pressure. Choice C is incorrect as stress, activity, and emotions can influence blood pressure but are not the sole determinants of hypertension.

Correct Answer: A

Rationale: The correct answer is A. Transporting specimens of body fluid in leakproof containers reduces the risk of exposure to HIV/AIDS. This precaution ensures that any potentially infectious material is securely contained. Choice B is incorrect as fusion inhibitors are not prescribed for reducing occupational risks. Choice C is incorrect as it does not directly address reducing occupational risks related to HIV/AIDS. Choice D is incorrect as it is essential for a nurse to clean the client's room, but with proper precautions in place to prevent exposure to bodily fluids.

Correct Answer: C

Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.