Correct Answer: B

Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation. Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.

Correct Answer: D

Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to reflect on their own thoughts and identify potential causes of their fatigue. It allows the patient to express their own insights and helps the nurse understand the underlying reasons for the fatigue. Choice A focuses on stress, which may not be the main cause of fatigue. Choice C is irrelevant to exploring the fatigue further. Choice D assumes that lack of sleep is the main issue, which may not be the case for the patient.

Correct Answer: A

Rationale: The correct answer is A because observing the client's gait while walking can provide valuable information about their physical mobility, balance, coordination, and any potential musculoskeletal issues. This assessment helps the nurse determine if the client requires any assistance, mobility aids, or further evaluation by a healthcare provider. Choices B and C are incorrect as observing gait does not directly provide information on personality or psychosocial status. Choice D is incorrect as gait observation is not specifically related to the rate of recovery from surgery. In summary, observing the client's gait is important for assessing physical mobility and identifying potential issues, making it the most relevant choice in this context.

Correct Answer: A

Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved. Step 2: Determines effectiveness of nursing interventions. Step 3: Validates if goals are met or adjustments are needed. Step 4: Reflects on the success of the care plan. Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care. Summary: - Choice B is incorrect as revising health history is part of assessment. - Choice C is incorrect as establishing priorities is part of the planning phase. - Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.