Correct Answer: A

Rationale: The first responsibility of a nurse when a patient falls is to assess the patient's injury. Assessing the patient's injury immediately allows the nurse to determine the severity of the fall and provide appropriate care and interventions. It is important to assess for any signs of injury, such as pain, swelling, bruising, or altered mobility, and to address any immediate medical needs. Once the patient's injury has been assessed, the nurse can then proceed to report the incident to the head nurse, write an incident report, and notify the physician if necessary.

Correct Answer: C

Rationale: Sensitivity refers to the ability of an instrument to detect small or fine differences among the subjects being studied. In the context of research or measurement tools, sensitivity is crucial for identifying subtle variations in the data that may hold importance in the analysis. A sensitive instrument can accurately measure and record even the smallest changes, making it a valuable criterion when assessing the quality of a measurement tool in research studies. High sensitivity indicates that the instrument is more likely to pick up on nuances and variations in the data, providing researchers with more detailed and accurate information to work with.

Correct Answer: C

Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.

Correct Answer: B

Rationale: Hip dysplasia is a common complication associated with untreated clubfoot in infants. If clubfoot is not treated promptly and properly, it can lead to abnormal development of the hip joint, resulting in hip dysplasia. This condition involves the abnormal formation of the hip socket, which can cause instability and potential dislocation of the hip joint. Early identification and treatment of clubfoot are important in preventing complications such as hip dysplasia.