The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?

Correct Answer: D

Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation. Incorrect Choices: A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns. C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication. D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.

Correct Answer: A

Rationale: The correct answer is A because pursed lip breathing helps to slow down and control the exhalation process, allowing the individual to exhale a smaller volume of air with more force. This helps to prevent air trapping in the lungs, improve oxygen exchange, and reduce shortness of breath. B: Incorrect - Pursed lip breathing does not increase expiration but rather controls it. C: Incorrect - While pursed lip breathing can promote deep breathing and better oxygen exchange, its primary purpose is to regulate exhalation volume. D: Incorrect - Pursed lip breathing does not specifically target the upper thorax but rather facilitates a more efficient breathing pattern by reducing air trapping in the lungs.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: 1. This step follows setting the agenda to focus on patient's main issues. 2. Allows nurse to gather essential information for effective care. 3. Builds rapport and shows patient-centered approach. Summary of other choices: A: Introductions are typically done at the beginning of the interview. C: Prematurely ending the interview may hinder rapport and information gathering. D: Administering medications is not the immediate priority after setting the agenda.

Correct Answer: C

Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.

Correct Answer: D

Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.

Correct Answer: C

Rationale: The correct answer is C because TPN (Total Parenteral Nutrition) is indeed given to patients with fluid restrictions, as it provides complete nutrition including fluids, electrolytes, and nutrients. On the other hand, PPN (Peripheral Parenteral Nutrition) is used for patients without fluid restrictions as it provides partial nutrition. A is incorrect because TPN is typically for long-term use and PPN for short-term use. B is incorrect as the caloric requirement does not determine the type of parenteral nutrition. D is incorrect because both TPN and PPN can be used for patients who are unable to eat orally.