The first thing to do for a nurse when an accident occurs is to find out if patient is conscious so that she could:

Correct Answer: A

Rationale: The correct answer is A: Reassure the patient. The first priority in any accident scenario is to ensure the patient's safety and well-being. By checking if the patient is conscious, the nurse can assess their immediate condition and provide reassurance to alleviate any distress or anxiety. This step establishes communication and trust, allowing for further assessment and appropriate actions to be taken. Calling relatives (B) may be important but not the immediate first step. Bringing the patient immediately to the hospital (C) is premature without assessing the patient first. Calling a doctor (D) can be done after assessing the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: To prevent respiratory obstruction. An ice collar is used to reduce swelling and inflammation, which can help prevent the abscess from compressing the airway and causing respiratory obstruction. This is crucial in cases of peritonsillar abscess to ensure the client's airway remains patent. Choices A, C, and D do not directly address the primary concern of preventing respiratory obstruction in this context.

Correct Answer: B

Rationale: The correct answer is B: "There is an increase in the intraocular pressure." Glaucoma is a group of eye conditions that damage the optic nerve due to increased pressure within the eye. High intraocular pressure is a key factor in the development of glaucoma. Choice A is incorrect because glaucoma is not associated with an increase in vitreous humor. Choice C is incorrect as glaucoma is not related to a decrease in aqueous humor. Choice D is incorrect because glaucoma is characterized by an increase, not a decrease, in intraocular pressure. Therefore, the most accurate description to explain glaucoma to a patient is the one that mentions the increase in intraocular pressure.

Correct Answer: A

Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting. Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.

Correct Answer: C

Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.

Correct Answer: A

Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.

Correct Answer: D

Rationale: The correct answer is D - Patency of airway and adequacy of respiration. This is the most important assessment during the acute stage of an unconscious patient like Mr. Franco because maintaining a clear airway and ensuring proper breathing are crucial for sustaining life. Without a patent airway and adequate respiration, the patient's oxygen supply could be compromised, leading to serious complications such as hypoxia or respiratory failure. Monitoring the airway and respiratory status takes precedence over other assessments in this scenario. A: Level of awareness and response to pain - While important, assessing level of awareness and response to pain is secondary to ensuring a patent airway and adequate respiration in an unconscious patient. B: Papillary reflexes and response to sensory stimuli - While these assessments provide valuable information about neurological function, they are not as critical as maintaining a clear airway and proper breathing in an unconscious patient. C: Coherence and sense of hearing - Coherence and sense of hearing are not as vital as