“Impaired skin integrity related to excess friction evidenced by redness.” The diagnostic focus in this nursing diagnosis is:

Correct Answer: B

Rationale: The correct answer is B: Skin integrity. In this nursing diagnosis, the focus is on the skin being impaired due to excess friction, as evidenced by redness. Skin integrity refers to the structural and functional intactness of the skin. The redness indicates a disruption in the skin's normal state, signifying impaired skin integrity. The other choices are incorrect because: A: Impaired - This term describes the overall condition but does not specifically address the issue of skin integrity. C: Excess friction - While this contributes to the issue, the primary focus should be on the resulting impaired skin integrity. D: Redness - While redness is an important indicator, it is a manifestation of the impaired skin integrity rather than the main diagnostic focus.

Correct Answer: C

Rationale: Performing a breast self-examination (BSE) helps in identifying any changes from previous examinations. This is crucial as it allows early detection of abnormalities such as lumps, areas of thickness, or fullness that may indicate breast cancer. Monitoring changes over time helps in prompt medical intervention if needed. The other choices (A, B, D) focus on specific findings rather than the overall purpose of detecting any changes, making them incorrect.

Correct Answer: B

Rationale: The correct answer is B: Current health promotion activities. This information is crucial for planning care as it provides insight into the client's current habits and practices that can impact their health. By knowing their current health promotion activities, healthcare providers can tailor care plans to support and enhance these activities. A: General health for the last 10 years may provide historical context but may not reflect the current status or needs of the client. C: Family history of diseases is important but may not directly impact the care planning for the individual client. D: Marital status is relevant for certain aspects of care planning, but it may not be as directly linked to the client's current health status and needs as their health promotion activities.

Correct Answer: C

Rationale: The correct answer is C: Cocaine. Sinus tachycardia is a condition characterized by a fast heart rate originating from the sinus node. Cocaine is a stimulant drug that can significantly increase heart rate, exacerbating sinus tachycardia. The nurse should question the client about cocaine use to address the potential cause of the elevated heart rate. Other choices are incorrect: A: Barbiturates are central nervous system depressants and can slow heart rate, not cause sinus tachycardia. B: Opioids are also central nervous system depressants and do not typically cause sinus tachycardia. D: Benzodiazepines are sedatives and do not commonly lead to sinus tachycardia.

Correct Answer: A

Rationale: The correct answer is A because rubbing with long smooth strokes from distal to proximal parts of the extremities follows the direction of venous blood flow towards the heart, aiding venous return. This action helps prevent blood pooling in the extremities. Circular massage strokes (B) may not be as effective in promoting venous return. Rubbing with short strokes from proximal to distal parts (C) goes against the natural flow of venous blood. Smooth long strokes alternating with chopping motions (D) may not consistently promote venous blood flow in the correct direction.