Lorraine, a 27 year old executive was brought to the ER for an unknown reason. She is starting to speak but her speech is disorganized and cannot be understood. On what level of anxiety does this features belongs?

Correct Answer: D

Rationale: Lorraine's disorganized, unintelligible speech indicates panic-level anxiety (D). Mild (A) enhances alertness; moderate (B) narrows focus but allows communication; severe (C) impairs function but speech remains coherent. Panic, the highest level, causes extreme disorganization, as seen here, with loss of rational thought and communication, per anxiety scales (e.g., Peplau). Her ER presentation aligns with panic's chaos, making D correct.

Correct Answer: C

Rationale: Taking a walk around the block is safe with a halo fixator, promoting mobility without risking cervical stability, as the device immobilizes the neck post-injury driving or bending (e.g., cooking, movie seating) strains it. Nurses encourage this activity, teaching balance and caution, ensuring recovery while preventing fixator displacement or injury.

Correct Answer: A

Rationale: Glomerular filtration rate (GFR) reflects kidney filtration capacity. Atrial natriuretic peptide (ANP) (choice A) increases GFR by dilating afferent arterioles and constricting efferent ones, boosting filtration in response to high blood volume. Histamine (choice B) affects local inflammation, not GFR directly. Vasopressin (choice C) reduces GFR by conserving water via tubular reabsorption, not filtration. Endothelium (choice D) is a tissue, not a substance, and likely a typo (endothelin constricts vessels, lowering GFR). A is correct, as ANP's vasodilatory effect enhances GFR. Nurses monitor this in heart failure or hypertension, adjusting care for renal perfusion.

Correct Answer: B

Rationale: Sunset sign downward eye deviation exposing sclera indicates neurological issues. Pyloric stenosis (choice A) causes vomiting, not eye signs. Hydrocephalus (choice B) raises intracranial pressure, pressing the brainstem, causing sunset sign as cranial nerves (III/VI) are affected. Tetralogy of Fallot (choice C) is cardiac, unrelated. Seizures (choice D) may alter gaze but not consistently this way. B is correct, a classic hydrocephalus feature. Nurses note it, measure head circumference, and support shunt placement, addressing pressure.

Correct Answer: C

Rationale: Primary prevention promotes health (A), includes immunization (B), educates (D) not when sick (C), per levels. C's illness focus is secondary/tertiary, making it untrue.

Correct Answer: C

Rationale: Coronary artery disease (CAD) is the U.S.'s leading killer, per CDC, making it the nurse's focus for a health fair on prevention and promotion. CAD artery blockages causing heart attacks outpaces lung cancer, emphysema, and strokes in mortality, driven by risks like hypertension or smoking. Addressing it involves teaching heart-healthy habits diet, exercise primary prevention to stop onset, vital in nursing's public health role. Lung cancer and emphysema, though serious, trail CAD, while strokes (cerebrovascular accidents) rank lower. A fair targeting CAD could screen cholesterol or promote activity, cutting its toll over 600,000 deaths yearly aligning with nursing's aim to tackle top health threats, enhancing community wellness through education and early action.

Correct Answer: C

Rationale: Phenytoin causes gingival hyperplasia, necessitating more frequent dental visits for gum care to prevent overgrowth and infection a key teaching point for clients. Meals don't enhance efficacy, sleep issues aren't prominent, and it doesn't reduce contraceptive effects significantly. Nurses emphasize oral hygiene, ensuring clients maintain health while managing seizures.

Correct Answer: C

Rationale: Self-esteem, part of self-concept (A), affects behavior (B), can improve (D) 'always positive' (C) isn't true, as it varies (e.g., low esteem), per theory. C's absolute fails, making it untrue.

Correct Answer: A

Rationale: Assessment, the first nursing process step, gathers data via interview (history), observation (vitals), and examination (physical) e.g., noting a patient's dyspnea. Planning sets goals, implementation acts, and evaluation reviews outcomes. This systematic data collection, per Gordon's framework, drives accurate care planning in practice.