The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?

Correct Answer: C

Rationale: Rationale: 1. Abdominal injection sites have a higher blood supply, leading to faster absorption. 2. Insulin absorption is faster in areas with more blood vessels. 3. Rapid absorption at the abdomen results in quicker onset of action. 4. Other sites may have slower absorption due to less blood flow. Summary: A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow. B: Incorrect. Absorption varies based on injection site blood supply. C: Correct. Abdominal injection sites have rapid insulin absorption. D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.

Correct Answer: B

Rationale: The correct answer is B because the problem-oriented approach involves focusing on the patient's presenting situation to identify the main issues and prioritize data collection. This step helps the nurse understand the immediate concerns and sets the direction for further assessment and interventions. Choice A is incorrect because completing questions in chronological order may not address the most urgent issues. Choice C is incorrect as accurate interpretations come after collecting relevant data. Choice D is incorrect as conducting an observational overview is part of the assessment process but not the first step in the problem-oriented approach.

Correct Answer: B

Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly. A, C, and D are incorrect: A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed. C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed. D: Skin appears flushed is an objective observation that can be directly seen.

Correct Answer: A

Rationale: The correct answer is A: Pneumocystis carinii pneumonia (PCP). PCP is the most common opportunistic infection in AIDS due to the weakened immune system, making patients vulnerable to this fungal infection. PCP is a leading cause of morbidity and mortality in AIDS patients. Toxoplasmosis (B) is also common but not as prevalent as PCP in AIDS. Candidiasis (C) is a common fungal infection but not the most common in AIDS. Mycoplasma pneumoniae (D) is a bacterial infection and not typically considered an opportunistic infection in AIDS.

Correct Answer: D

Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery. A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs. B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role. C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.

Correct Answer: A

Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life. Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.

Correct Answer: B

Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance. A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention. C: Thyroid hormone does not directly influence sodium retention. D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.

Correct Answer: C

Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.

Correct Answer: D

Rationale: The correct answer is D: Maturates T cells. The thymus gland is crucial for the maturation of T cells, a type of white blood cell that plays a central role in the adaptive immune response. T cells mature in the thymus through a process of selection and education, where they learn to distinguish self from non-self antigens. This process is essential for the development of a functional immune system. Choices A, B, and C are incorrect because the thymus gland does not play a role in the maturation of B cells, platelets, or red blood cells, respectively.