In determining and fulfilling the nursing care needs of the patient, which step involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status?

Correct Answer: A

Rationale: The correct answer is A, 'Evaluation.' Evaluation in nursing involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status. This step helps determine the outcomes of the care provided and if any changes are needed. Choice B, 'Planning,' focuses on developing a plan of care based on the assessment findings. Choice C, 'Implementation,' involves carrying out the plan of care. Choice D, 'Assessment,' is the initial step in the nursing process that involves gathering data about the patient's health status.

Correct Answer: A

Rationale: The correct answer is A: Red meat. Red meat is high in purines, which can exacerbate gout attacks. Gout is a form of arthritis that occurs when high levels of uric acid in the blood lead to the formation of urate crystals in the joints. Purine-rich foods can increase uric acid levels, leading to gout symptoms. Chicken and fish are lower in purines compared to red meat, making them better choices for individuals with gout. Dairy products are generally considered safe for gout patients and may even have a protective effect against gout.

Correct Answer: A

Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.

Correct Answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

Correct Answer: C

Rationale: The correct answer is C. This statement is true because both prescription medications and over-the-counter medications, along with herbal remedies, can interact with food. Choice A is incorrect because over-the-counter medications can also interact with food or nutrients. Choice B is incorrect as not all prescription medications have significant interactions with food. Choice D is misleading because herbal products are not always safe, as they can have side effects and interact with other medications.

Correct Answer: B

Rationale: The correct answer is B: Writing letters. Writing requires fine motor skills, which are often impaired in a right-handed person with a right-sided CVA. Eating meals (choice A), combing the hair (choice C), and dressing every morning (choice D) involve gross motor skills and may not be as challenging for a right-handed individual with a right-sided CVA compared to the fine motor skill required for writing.

Correct Answer: D

Rationale: The correct answer is D, High-density lipoprotein (HDL). HDL is known as 'good' cholesterol because it helps transport excess cholesterol from tissues back to the liver for removal from the body. Very low-density lipoprotein (VLDL) (choice A) and intermediate-density lipoprotein (choice B) are involved in transporting triglycerides. Low-density lipoprotein (LDL) (choice C) is known as 'bad' cholesterol as it can deposit cholesterol in the walls of arteries.

Correct Answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.

Correct Answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.