Correct Answer: C

Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.

Correct Answer: B

Rationale: The correct answer is B because client-centered care emphasizes involving clients in decision-making. During evaluation, assessing if the care plan aligns with the client's preferences and goals ensures personalized and effective care. This approach enhances client satisfaction, engagement, and outcomes. Incorrect choices: A: Not considering the client's input goes against client-centered care principles. C: Prioritizing institutional policies over client feedback neglects the client's individual needs. D: Focusing solely on measurable clinical outcomes may not capture the holistic view of the client's well-being.

Correct Answer: A

Rationale: The correct answer is A: Anthropometric measurements. This includes height, weight, and body mass index, which are crucial indicators of the nutritional status of a patient with Crohn's disease. It helps assess malnutrition, muscle wasting, and overall nutritional health. Dry skin (B), bleeding gums (C), and facial rubor (D) are not direct indicators of nutritional health in a patient with Crohn's disease. Dry skin may indicate dehydration, bleeding gums may suggest poor oral hygiene or gum disease, and facial rubor may be a sign of inflammation but are not specific to nutritional status.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs. Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided. In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.