Kris is a hospitalized movie star. A nursing assistant takes her picture without permission and sells it to a local newspaper. The nursing assistant could be quilts of:

Correct Answer: A

Rationale: This scenario falls under the category of invasion of privacy. Invasion of privacy occurs when a person's private information or images are shared or used without their consent, leading to an intrusion of their private life. In this case, Kris, as a hospitalized movie star, had her picture taken without permission by the nursing assistant, which was later sold to a local newspaper. Kris has a right to privacy, especially during a vulnerable time like being hospitalized, and the nursing assistant violated that right by taking and selling her picture without consent. This action constitutes an invasion of privacy.

Correct Answer: A

Rationale: The correct nursing intervention for Almira would be to advise her to eat her meals. This is important in promoting her health and well-being, especially if she has been neglecting her own nutrition due to stress or caring for her son, Jay. Providing proper nutrition is a basic aspect of nursing care that supports the overall health and recovery of the patient. By encouraging Almira to prioritize her own nutrition, the nurse can help ensure that she has the physical strength and energy needed to take care of herself and her son effectively.

Correct Answer: D

Rationale: The patient is presenting with symptoms and laboratory findings consistent with a paraneoplastic syndrome related to Hodgkin lymphoma. In this case, the fever, chills, generalized malaise, pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement are all indicative of a paraneoplastic syndrome associated with Hodgkin lymphoma. Paraneoplastic syndromes are a group of disorders that are triggered by an abnormal immune response to a neoplasm, such as Hodgkin lymphoma, leading to various systemic manifestations.

Correct Answer: A

Rationale: In a patient with suspected pulmonary TB, the most appropriate diagnostic test for confirming the diagnosis is the sputum acid-fast bacilli (AFB) smear and culture. This test involves examining sputum samples under the microscope for the presence of acid-fast bacilli, which are characteristic of Mycobacterium tuberculosis, the bacteria that causes TB. Additionally, culturing the sputum allows for the bacteria to grow in a controlled environment, further confirming the diagnosis. In the given scenario, the patient's symptoms (cough, weight loss, night sweats, hemoptysis), along with chest X-ray findings of upper lobe infiltrates and cavitation, are highly suggestive of pulmonary TB. Therefore, performing a sputum AFB smear and culture is crucial for definitive diagnosis and initiation of appropriate treatment. The other options (Tuberculin skin test, Interferon

Correct Answer: C

Rationale: It is essential for nurses to record vital signs and notes on a patient as soon as they obtain them. This allows for accurate and timely documentation of crucial information related to the patient's health status. By recording the information promptly, nurses can ensure that they do not forget important details and can provide effective care based on accurate data. Waiting for lunch break or after completing other tasks can lead to delays in documentation, which may compromise patient care and safety. Therefore, the ideal and proper time for recording vital signs and notes is immediately after obtaining them.

Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

Correct Answer: C

Rationale: In this situation, the most appropriate way for the nurse to handle it would be to encourage the mother to keep calm because the health care team is doing their best to help Ramon recover. This response acknowledges the mother's concerns and reassures her that everything possible is being done for her son's well-being. It also helps to foster trust and rapport between the nurse, mother, and the healthcare team, which is important for effective communication and support during a challenging time. Promoting a sense of calm and trust in the healthcare professionals can help alleviate the mother's anxiety and stress, allowing her to focus on being a supportive presence for her son.

Correct Answer: A

Rationale: In prioritizing nursing diagnoses, the nurse should consider issues that pose the greatest risk to the patient's immediate well-being. A fluid volume deficit can lead to dehydration and potentially life-threatening complications, making it a priority to address. It is crucial to restore fluid balance to maintain normal body functions and prevent further deterioration of the patient's condition. Ensuring adequate hydration is essential for the patient's overall health and recovery. The other options, such as risk for pain, coping, and body image disturbances, while important, are not as urgent as addressing a fluid volume deficit.

Correct Answer: A

Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.