The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first?

Correct Answer: B

Rationale: When assessing a patient's abdomen, the nurse must follow a systematic approach to ensure accurate findings, starting with the least invasive technique. Inspection (Choice B) is the first step because it involves observing the abdomen for visible signs like distension, scars, or asymmetry without altering the body's natural state. Auscultation (Choice A) comes next, as it listens to bowel sounds, but performing percussion (Choice C) or palpation (Choice D) first could stimulate bowel motility or cause discomfort, potentially skewing the auscultation results. Inspection provides a baseline visual assessment, allowing the nurse to note abnormalities before proceeding to hands-on techniques. For instance, palpating or percussing too early might increase peristalsis, leading to misleading bowel sound interpretations. This sequenceinspection, auscultation, percussion, palpationis a standard protocol in nursing practice to maintain accuracy and patient comfort. Therefore, starting with inspection (Choice B) ensures the assessment is both logical and effective, making it the correct answer.

Correct Answer: B

Rationale: Pressure ulcers require optimal nutrition for healing, and inadequate protein intake (Choice B) is the most likely reason for non-healing despite repositioning and skin care. Protein is essential for collagen synthesis, tissue repair, and immune function; deficiency causes negative nitrogen balance, stalling granulation and epithelialization. Prolonged bed rest already reduces muscle mass, exacerbating protein needs. Vitamin D (Choice A) aids calcium absorption for bone health, not directly wound healing, though it supports overall recovery. Massaging the affected area (Choice C) is contraindicated, as it damages fragile tissue, and isn't part of standard care here. Low calcium (Choice D) affects bones more than soft tissue repair. For example, a client needing 1.5-2 g/kg protein daily but receiving less won't heal, even with turning, as protein fuels fibroblast activity and angiogenesis. Thus, Choice B is the correct and primary factor.

Correct Answer: B

Rationale: A WBC count of 100/µL (normal: 4,500-11,000) indicates severe leukopenia, likely neutropenia, making infection prevention (Choice B) the most important goal. With Hb (14 g/dL, normal: 13.5-17.5) and HCT (40%, normal: 38-50%) within range, anemia or fluid imbalance isn't a concern, ruling out fluid balance (Choice A) and rest (Choice C). Injury prevention (Choice D) is less urgent, as bleeding risk requires low platelets, not specified here. A WBC this lowe.g., post-chemotherapyleaves the client defenseless against pathogens; even minor infections can become septic. Interventions like isolation, hand hygiene, or antibiotics prioritize this risk. For example, a fever in neutropenia is a medical emergency, unlike fatigue or bruising. Survival hinges on infection control, making Choice B the correct and critical goal.

Correct Answer: C

Rationale: The rhythmic biologic clock in humans is the 'circadian rhythm' , a roughly 24-hour cycle governed by the hypothalamic suprachiasmatic nucleus (SCN), syncing bodily functions like sleep, temperature, and hormone release to day-night cues. 'Sleep-wake cycle' is a component of this rhythm, not its name; it's the observable outcome, not the mechanism. 'Alert-unaware process' is fictitious, lacking scientific basis. 'Yo-yo theory' doesn't exist in sleep science. For instance, the SCN adjusts melatonin release at dusk, promoting sleep, and cortisol at dawn, enhancing alertnessdisruptions (e.g., jet lag) show its 24-hour rule. Nursing education, per Taylor, emphasizes circadian rhythm as the internal pacemaker, evident in shift workers' struggles. Unlike a mere cycle, it's a genetically driven clock, making Choice C the precise term and correct answer.

Correct Answer: D

Rationale: Medications impact sleep via physiological or neurological effects. 'Ambien' , or zolpidem, is least likely to harm sleep quality; it's a sedative-hypnotic designed to induce and maintain sleepe.g., shortening sleep latency to 15 minuteswithout altering architecture long-term, per prescribing data. 'Diuretic' disrupts sleep via nocturiae.g., waking 3 times to void after furosemide. 'Steroid' , like prednisone, causes insomniae.g., 20% of users report wakefulness from CNS stimulation. 'Antidepressant' , like SSRIs, alters REMe.g., fluoxetine delays REM onset by 30 minutesdisrupting quality. Ambien's targeted action (GABA enhancement) contrasts with others' side effects, aligning with Taylor's pharmacology. Choice D is correct as it enhances, not impairs, sleep.