Lifestyle-related diseases in general share common risk factors. These are the following except:

Correct Answer: A

Rationale: The correct answer is A: Physical activity. Lifestyle-related diseases, such as heart disease and type 2 diabetes, are often linked to common risk factors like smoking, genetics, and poor nutrition. However, physical activity is not a risk factor but rather a protective factor that can help prevent these diseases. Regular exercise can improve cardiovascular health, manage weight, and reduce the risk of chronic conditions. Therefore, physical activity does not fit the criteria of a common risk factor shared by lifestyle-related diseases. Smoking, genetics, and poor nutrition are directly associated with an increased risk of developing such diseases.

Correct Answer: C

Rationale: The correct nursing diagnosis of "Excessive fluid volume" takes highest priority for the client with chronic renal failure due to the presenting signs and symptoms of fluid overload: high blood pressure, neck vein distention, and bibasilar crackles indicating fluid in the lungs. Managing fluid volume is crucial to prevent complications such as pulmonary edema and worsening renal function. Fear (A) is not the priority as physiological needs should be addressed first. Urinary retention (B) is not the priority as the client's symptoms are more indicative of fluid overload rather than urinary retention. Self-care deficient: Toileting (D) is not the priority as it does not address the immediate physiological threat posed by excessive fluid volume.

Correct Answer: A

Rationale: The correct answer is A: By indenting the skin ½" to ¾" (1.3 to 1.9 cm). Light palpation is performed by gently pressing down on the skin with the fingertips to a depth of ½" to ¾" to assess superficial structures. This depth allows the nurse to feel for tenderness, texture, temperature, and moisture without causing discomfort or disrupting deeper tissues. Choices B, C, and D are incorrect because they describe depths or techniques that are too deep or not appropriate for light palpation, which should be gentle and shallow. Option B (1" to 2") and C (1" using both hands) would be too deep and could potentially cause discomfort to the patient. Option D (1" and then releasing quickly) does not maintain the consistent light pressure needed for accurate assessment of superficial structures.

Correct Answer: D

Rationale: The correct answer is D: Pull the pinna of the ear backwards and upwards. This direction allows for proper alignment of the ear canal with the tympanic membrane, ensuring accurate temperature measurement. Pulling the pinna backwards and upwards straightens the ear canal for better contact with the thermometer, leading to a more precise reading. Choices A, B, and C would not facilitate optimal alignment for accurate tympanic temperature measurement and could potentially result in an incorrect reading.

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate. A sudden change in the client's respiratory rate, especially if the client becomes profoundly short of breath, indicates a critical change in condition such as respiratory distress or failure. This is a priority assessment as it directly relates to the client's oxygenation and respiratory status. In this scenario, the client's increased respiratory rate of 26 breaths per minute, along with the symptoms of profound shortness of breath and gray skin color, indicates potential respiratory compromise. Monitoring the respiratory rate would have alerted the nurse first to the client's deteriorating condition. Summary of other choices: A: Heart rate - Although an elevated heart rate of 110 bpm is present, it is less indicative of respiratory distress compared to the respiratory rate in this situation. C: Blood pressure - The blood pressure of 120/70 is within normal range and may not be the first indicator of respiratory distress. D: Temperature - A temperature of 100.4 degrees Fahrenheit is slightly