For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?

Correct Answer: C

Rationale: The correct answer is C because it focuses on the client actively engaging in reducing tension, which is essential in managing anxiety. This outcome is measurable and client-centered. A: Verbalizing feelings is important, but it does not necessarily lead to reduction in anxiety. B: Not guessing prognosis is helpful, but it does not address the active management of anxiety. D: Stopping seeking information may not be beneficial as knowledge can empower the client in coping with the diagnosis.

Correct Answer: C

Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process checks for errors, inconsistencies, and completeness in the data. By comparing data with other sources, nurses can verify the reliability and correctness of the information. Choice A is incorrect because data validation typically occurs after data collection and before data interpretation. Choice B is incorrect because validation is about ensuring data accuracy, not about professional standards. Choice D is incorrect because data interpretation focuses on analyzing and making sense of the data, not on professional standards or validation processes.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A: Inform the physician. This is essential because a sudden change in vital signs may indicate a critical condition that requires immediate medical attention. The physician needs to be informed promptly to assess the situation and provide appropriate interventions. Summary: - B: Changing environmental settings is not a priority when dealing with sudden changes in vital signs. - C: Altering diet intake is not an immediate response to sudden changes in vital signs. - D: Decreasing physical activity may not address the underlying cause of the sudden change in vital signs.

Correct Answer: C

Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.

Correct Answer: C

Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.

Correct Answer: A

Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction. Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.

Correct Answer: A

Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight. - Choice B is about interpreting physical signs, not client data validation. - Choice C involves documenting objective findings, not validating client information. - Choice D pertains to a client's complaint, not necessarily requiring validation.

Correct Answer: C

Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.