Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing, which is a general observation, before moving on to more specific details. This approach allows the nurse to gather comprehensive information systematically. A: Gordon’s Functional Health Patterns involves assessing a patient's health across several categories, not specifically related to wound care. B: Activity-exercise pattern assessment focuses on the patient's physical activity and exercise routines, not the wound dressing. D: Problem-oriented assessment involves identifying and addressing specific health issues, rather than starting with a general observation like the appearance of a surgical dressing.

Correct Answer: A

Rationale: Step 1: Vitamin B12 is absorbed in the small intestine with the help of intrinsic factor produced by parietal cells in the stomach. Step 2: Intrinsic factor binds to vitamin B12, forming a complex that is then absorbed in the ileum. Step 3: If intrinsic factor is lacking (as seen in pernicious anemia), vitamin B12 absorption is impaired, leading to megaloblastic anemia. Step 4: Administering cyanocobalamin bypasses the need for intrinsic factor. Step 5: Thus, intrinsic factor influences Vitamin B12 absorption. Other choices (B, C, D) do not play a direct role in Vitamin B12 absorption.

Correct Answer: B

Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache. Incorrect choices: A: To prevent confusion - Irrelevant to the procedure. C: To prevent seizures leakage - Seizures are not a concern with spinal blocks. D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.

Correct Answer: C

Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.

Correct Answer: D

Rationale: The correct answer is D: Check for neurologic status. This is the first action because assessing the patient's neurologic status helps identify any immediate threats to their health and guides further interventions. It is crucial to ensure the patient's safety and prioritize interventions based on their neurologic status. Starting an IV for fluids (A), getting an ECG (B), and placing a Foley catheter (C) are important interventions but should come after assessing the patient's neurologic status to address any urgent issues first.