Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.

Correct Answer: B

Rationale: The stomach is the organ responsible for the mechanical and chemical digestion of food. When food enters the stomach, it is mixed with stomach acid and enzymes to break down the food into smaller particles. This process helps prepare the food for further digestion and absorption of nutrients. The stomach also plays a key role in the absorption of some nutrients, such as certain vitamins and minerals. Additionally, the stomach's muscular contractions help mix the food with digestive enzymes and propel the partially digested food into the small intestine for further processing and absorption. The liver, pancreas, and large intestine have vital functions in the digestive system, but the stomach is the primary organ responsible for the initial digestion and absorption of nutrients.

Correct Answer: B

Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.

Correct Answer: C

Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.

Correct Answer: D

Rationale: The priority nursing initiative for Nurse May should be to set up a mental health program in the community. This proactive approach focuses on prevention, early intervention, and support for individuals experiencing mental health issues. By setting up a mental health program, Nurse May can address the root causes of mental problems in young adults in the community, provide education and awareness, offer counseling services, and promote mental well-being. This initiative can have a long-term impact on the mental health of individuals and help reduce the incidence of mental problems in the community. Setting up a mental health program is a holistic and sustainable approach to addressing mental health issues in the community.