In doing a nutritional assessment for Mrs. Collins who wants to lose weight, what should the nurse initially do?

Correct Answer: A

Rationale: The correct answer is A) Ask her to describe her actual food intake and behaviors influencing eating. This is the initial step in conducting a nutritional assessment for Mrs. Collins who wants to lose weight. Understanding her current dietary habits, food preferences, portion sizes, eating patterns, and factors influencing her eating behaviors is crucial in developing a personalized and effective weight loss plan. Option B) Determine who does the cooking and shopping is incorrect because while it may provide some insight into Mrs. Collins' access to healthy foods, it does not directly address her individual dietary habits and behaviors. Option C) Determine what she knows about the basic four food groups is incorrect as it focuses on basic nutritional knowledge rather than Mrs. Collins' specific eating habits and behaviors. Option D) Determine biochemical data such as urinalysis and blood chemistries is incorrect because these tests are not typically the initial step in a nutritional assessment for weight loss. They may be useful later on to assess specific nutrient deficiencies or metabolic conditions, but they are not the first priority in this context. In an educational context, understanding the rationale behind each option helps nurses develop critical thinking skills to prioritize and implement appropriate interventions based on individual patient needs. By focusing on Mrs. Collins' actual food intake and eating behaviors, the nurse can gather valuable information to support her weight loss goals effectively.

Correct Answer: B

Rationale: In the context of developing a discharge plan for a patient requiring home-care services, assessing the availability of needed community services (Option B) is crucial. This is because ensuring the patient has access to necessary support services in the community is essential for their successful transition from hospital to home. By assessing the availability of these services, healthcare providers can coordinate appropriate care, such as home health aides, physical therapy, or meal delivery services, to meet the patient's needs and promote their recovery and well-being. Options A, C, and D are incorrect in this scenario. While the patient's nursing diagnosis (Option A) is important for guiding care planning, it does not directly address the practical aspect of coordinating community services for home care. Assessing the patient's functional abilities (Option C) is essential but focuses more on the individual patient's physical capabilities rather than the external support services needed for home care. Similarly, evaluating the patient's family dynamics (Option D) is important for understanding the social support available, but it does not directly address the logistical aspect of arranging community services. In an educational context, understanding the importance of assessing the availability of community services when developing a discharge plan reinforces the holistic approach to patient care. It emphasizes the need for comprehensive planning that considers not only the patient's medical condition but also the practical support services required for a successful transition to home care. This knowledge is essential for nursing students and healthcare professionals to ensure quality patient-centered care and promote positive health outcomes.

Correct Answer: B

Rationale: In this scenario, the correct nursing orders for Mary Thomas, who presents with symptoms of red, teary eyes, a runny nose, and a stuffy head, would be option B: Increased fluids, steam inhalation, and rest. The rationale behind this choice is rooted in understanding the symptoms presented by Mary. Her symptoms suggest she is likely suffering from allergic rhinitis or a common cold. Increasing fluids helps to hydrate her, which is important during illness. Steam inhalation can help relieve nasal congestion and soothe irritated sinuses. Rest is crucial for the body to focus its energy on fighting off the infection or allergen. Options A and C include aspirin and cough syrup, which are not typically recommended for allergic rhinitis or a common cold as they may not address the root cause of the symptoms or could have potential side effects. Antihistamines would be more appropriate than aspirin for allergy symptoms. Auscultation and percussion of the chest (option D) are not indicated based on the symptoms presented by Mary, as they are more relevant for respiratory conditions like pneumonia or bronchitis. In an educational context, this question highlights the importance of assessing symptoms accurately to provide appropriate nursing care. It emphasizes the significance of evidence-based practice in selecting interventions tailored to the individual's condition, promoting critical thinking skills essential for nursing practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Elevation in temperature is consistent with normal postoperative recovery. Postoperative patients commonly experience a temporary elevation in temperature due to the body's natural response to surgery, known as the inflammatory phase of wound healing. This transient increase in temperature is a normal part of the healing process and does not necessarily indicate an infection. Option A is incorrect because a decrease in blood pressure alone does not always indicate imminent shock. Shock is a complex physiological state involving inadequate tissue perfusion, which may present with other signs and symptoms beyond just a decrease in blood pressure. Option B is incorrect because an elevated temperature in the immediate postoperative period is more likely related to the body's response to tissue trauma rather than a wound infection. Wound infections typically manifest with localized signs such as redness, swelling, warmth, and purulent drainage. Option C is incorrect as a decrease in blood pressure postoperatively is not consistent with hypertension, which is characterized by persistently elevated blood pressure readings. Educationally, understanding the normal physiological responses to surgery and differentiating between expected postoperative changes and signs of complications is crucial for nurses and healthcare providers to provide appropriate care and interventions for postoperative patients. It is essential to monitor vital signs closely, interpret them accurately, and respond appropriately to ensure optimal patient outcomes.

Correct Answer: A

Rationale: In the context of pharmacology and nursing care, the most appropriate nursing action for Mr. Jones' persistent productive cough would be to increase intake of warm liquids (Option A). This is because warm liquids can help soothe the throat and facilitate the loosening of mucus, making it easier for Mr. Jones to expectorate and alleviate his cough. Option B, administering narcotic cough medication, is not the most appropriate initial nursing action for a productive cough, as it may suppress the cough reflex and hinder the body's natural mechanism of clearing the airways of mucus. Monitoring the amount of sputum produced each day (Option C) is relevant in assessing the effectiveness of interventions, but it is not the most immediate nursing action to address Mr. Jones' current symptom of a persistent productive cough. Placing the patient on strict bed rest (Option D) may not directly address the cough itself and could potentially lead to complications such as pneumonia or deconditioning. In an educational context, understanding the rationale behind selecting the most appropriate nursing action for a specific symptom like a persistent productive cough is essential for providing safe and effective patient care. Nurses need to prioritize interventions based on evidence-based practices to promote optimal patient outcomes.