Correct Answer: D

Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions. A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions. B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario. C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.

Correct Answer: A

Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.

Correct Answer: C

Rationale: Rationale: 1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths. 2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume. 3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing. 4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator. 5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient. 6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.

Correct Answer: B

Rationale: The correct answer is B because it acknowledges the partner's feelings while providing information that may help them cope. By stating that unresponsiveness doesn't mean the patient can't hear, the nurse highlights the importance of the partner's presence for emotional support. It encourages the partner to continue visiting, emphasizing their role in providing comfort to the patient. Choice A is incorrect as it dismisses the partner's feelings and lacks empathy. Choice C is incorrect as it implies the nurse will only involve the partner if the patient responds, neglecting the partner's emotional needs. Choice D is incorrect as it deflects responsibility from addressing the partner's concerns and suggests involving other family members without addressing the partner's feelings directly.

Correct Answer: A

Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.