One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?

Correct Answer: A

Rationale: The correct answer is A: Uplifting memories. When assessing hope in a terminally ill patient, identifying uplifting memories can foster hope by providing emotional support, positive experiences, and a sense of purpose. Memories can inspire optimism and comfort in difficult times. B: Ignoring negative outcomes is incorrect as it does not address the patient's emotional needs or promote coping strategies. C: Envisioning one specific outcome is incorrect because hope should encompass a range of possibilities, not just one specific outcome. D: Avoiding an actual or potential threat is incorrect as it focuses on avoidance rather than on promoting positive emotions and psychological well-being.

Correct Answer: C

Rationale: The correct answer is C: Clinical decision support system. A clinical decision support system is a type of system or design that helps healthcare professionals, including nurses, in making clinical decisions by providing them with relevant information and knowledge. This system assists in analyzing data to generate patient-specific recommendations or alerts to improve patient care. In the given scenario, the nurse's need to find, evaluate, and use information effectively aligns with the purpose of a clinical decision support system. This system enables the nurse to access evidence-based information, guidelines, and recommendations to enhance their decision-making process and improve patient outcomes. Summary of why other choices are incorrect: A: Computer competency does not equate to informatics competency. While computer skills are important, informatics involves a deeper understanding of using information effectively in practice. B: This choice provides a detailed explanation of informatics but does not directly address the type of system or design the nurse would be using to find, evaluate, and use information effectively. D: Nursing process

Correct Answer: B

Rationale: The correct answer is B because pregnant patients with Class II heart disease should avoid strenuous activity to prevent further strain on the heart. Strenuous activity can increase the risk of complications in these patients. Option A is incorrect as excessive weight gain can exacerbate heart disease. Option C is incorrect because limiting fluid intake can lead to dehydration, which is harmful during pregnancy. Option D is incorrect as a diet high in calcium is not specifically indicated for pregnant patients with Class II heart disease.

Correct Answer: C

Rationale: The correct answer is C: Degree of glycemic control before and during the pregnancy. Proper glycemic control is crucial in managing complications in a pregnant patient with diabetes. Uncontrolled blood sugar levels can lead to maternal, fetal, and neonatal complications. Monitoring and maintaining stable blood glucose levels before and during pregnancy help reduce the risk of adverse outcomes. A: Evaluation of retinopathy by an ophthalmologist - Although important for overall health, retinopathy does not directly impact maternal, fetal, and neonatal complications in diabetes during pregnancy. B: The patient’s stable emotional and psychological status - While emotional and psychological well-being are important, they do not directly affect complications related to diabetes in pregnancy. D: Total protein excretion and creatinine clearance within normal limits - While these are indicators of kidney function, they are not the most crucial factors in managing complications in a pregnant patient with diabetes.

Correct Answer: D

Rationale: The correct answer is D: Previous perforation of the eardrum. A perforated eardrum can lead to hearing loss as it affects the transmission of sound waves to the inner ear. This is the most likely link to the patient's hearing deficit as trauma or injury to the eardrum can directly impact hearing. Incorrect choices: A: Recent completion of radiation therapy for treatment of thyroid cancer - Radiation therapy for thyroid cancer typically does not directly affect hearing. B: Routine use of quinine for management of leg cramps - Quinine use is associated with tinnitus (ringing in the ears) but not typically with hearing loss. C: Allergy to hair coloring and hair spray - Allergy to hair products is not directly related to hearing loss. In summary, the most likely cause of the patient's hearing deficit based on the health history provided is the previous perforation of the eardrum, as it directly affects the transmission of sound waves to the inner ear.

Correct Answer: B

Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.

Correct Answer: B

Rationale: The correct answer is B: Acute pain related to misplaced endometrial tissue. This nursing diagnosis should be prioritized because endometriosis commonly presents with severe pelvic pain. Managing pain is crucial for the patient's comfort and quality of life. Anxiety (choice A) is not the priority as pain management takes precedence. Ineffective tissue perfusion (choice C) is not a priority unless the patient is actively hemorrhaging. Excess fluid volume (choice D) is not typically associated with endometriosis. Prioritizing pain management will address the immediate and most distressing symptom for the patient.

Correct Answer: C

Rationale: The correct answer is C because documenting medication administration is critical for patient safety and continuity of care. By documenting the pain medication received, the nurse ensures accurate medication tracking and prevents errors. Choice A is incorrect as it lacks specific, objective information. Choice B is irrelevant to patient care. Choice D is inappropriate and violates patient confidentiality.

Correct Answer: C

Rationale: The correct answer is C: The patient has diabetes. Diabetes can lead to diabetic retinopathy, a common cause of low vision. By knowing the patient's medical history, the nurse can recommend appropriate low vision aids and refer the patient to an ophthalmologist for further evaluation and management. Incorrect choices: A: The patient uses OTC NSAIDs - NSAIDs are not relevant to managing low vision. B: The patient has a history of stroke - A history of stroke is not directly related to low vision. D: The patient has Asian ancestry - Ancestry is not a factor in managing low vision.