Evidence-based nursing practice is:

Correct Answer: A

Rationale: The correct answer is A because evidence-based nursing practice involves combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances. This approach ensures that nursing interventions are based on the best available evidence, tailored to individual patient needs, and aligned with patient preferences. It emphasizes the integration of research evidence, clinical expertise, and patient values to optimize patient outcomes. Choice B is incorrect because evidence-based nursing practice involves a comprehensive review of multiple research studies, not just one or two articles. Choice C is incorrect because completing a literature search is just one step in the evidence-based practice process, which also involves critically appraising and applying the evidence to patient care. Choice D is incorrect because evidence-based practice focuses on using research evidence, not value-based resources, to guide nursing actions.

Correct Answer: C

Rationale: The true leg length should be measured between the ASIS (anterior superior iliac spine) and the medial malleolus. This is because the ASIS is a prominent bony landmark on the pelvis, representing the top of the femur, and the medial malleolus is the bony prominence on the inner side of the ankle, representing the bottom of the tibia. Measuring between these points provides an accurate representation of the actual length of the leg. Choice A (Greater trochanter to lateral malleolus) is incorrect because the greater trochanter is not the starting point for measuring leg length. Choice B (Umbilicus and lateral malleolus) is incorrect as the umbilicus is not a reliable reference point for leg length measurement. Choice D (Anterior inferior iliac spine and medial malleolus) is incorrect because the AIIS is not typically used as a reference point for leg length measurement.

Correct Answer: D

Rationale: In Erb's palsy, the upper trunk (C5-C6) of the brachial plexus is affected. This leads to weakness or paralysis of the shoulder and elbow muscles. The C5-C6 nerve roots are commonly injured during childbirth trauma. The other choices are incorrect because Erb's palsy specifically involves the upper trunk, not the lower trunk (C8-T1), both upper and lower trunks, or the middle trunk (C7). Therefore, the correct answer is D.

Correct Answer: D

Rationale: The correct answer is D: Wound contracture. When a burn patient is splinted in a comfortable position for grafted burns to heal, there is a risk of wound contracture due to prolonged immobility. Wound contracture refers to the tightening and shrinking of the skin and underlying tissues, leading to restricted joint movement and functional impairment. This complication can result in long-term disability and decreased quality of life for the patient. Choices A, B, and C are incorrect: A: Tendon rupture is not a typical complication of splinting a burn patient in a comfortable position. B: Skin breakdown may occur if the splint is too tight or if there is excessive pressure on certain areas, but it is not the primary risk associated with this scenario. C: Mechanical falls are unrelated to the positioning of the burn patient for graft healing.

Correct Answer: C

Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that require attention after addressing first-level problems but before third-level problems. Abnormal laboratory values fall into this category because they may indicate a potential for worsening health conditions if left untreated. Low self-esteem (choice A) is typically a third-level priority, lack of knowledge (choice B) can usually be addressed as a lower priority, and severely abnormal vital signs (choice D) are considered first-level priorities due to their immediate threat to the patient's well-being.