The nurse is caring for a client with a traumatic brain injury who has an intracranial pressure (ICP) monitoring device in place. The ICP reading suddenly increases to $25 \mathrm{mmHg}$. Which action should the nurse take first?

Correct Answer: D

Rationale: ICP of 25 mmHg requires elevating HOB to 30 degrees (D) first to reduce pressure via venous drainage. Notification (A), pupils (B), or mannitol (C) follow. D is correct. Rationale: Immediate elevation lowers ICP non-invasively, a first-line action per neurocare protocols, buying time for further assessment.

Correct Answer: D

Rationale: Betty Neuman's Health Care System Model (1970s) focuses on managing stressors intrapersonal (emotions), interpersonal (relationships), extrapersonal (finances) via prevention levels. For instance, primary prevention educates a hypertensive patient. Henderson aids needs, Orem self-care, and Parse becoming, but Neuman's stressor-centric system promotes stability, widely used in stress-related care like mental health or chronic illness management.

Correct Answer: B

Rationale: Falsely saying Mr. Gary has AIDS is defamation (B) reputation-harming lie, per law. Privacy (A) needs truth, assault (C) threat, battery (D) touch. B fits slanderous falsehood, making it correct.

Correct Answer: D

Rationale: Side-lying position post-Billroth II (gastrectomy) prevents dumping syndrome by slowing gastric emptying and reduces aspiration risk from nasogastric drainage supine or Fowler's increases reflux, prone is impractical. Nurses use this positioning, monitoring for rapid pulse or nausea, ensuring comfort and stability after gastric surgery.

Correct Answer: A

Rationale: Intellectual needs in long-term care involve cognition and learning, shaping health responses. Educating a diabetic client on foot care meets this, enhancing understanding of self-management e.g., preventing ulcers tied to past experiences and education level. Showing a video on modified activities engages residents, teaching adaptive skills like chair exercises, boosting cognitive engagement. Shutting a cafeteria addresses safety, not intellect. Referring for grief targets emotional needs, not cognitive. These actions foot care, video stimulate thinking and problem-solving, key for older adults' autonomy and health behaviors, aligning with nursing's holistic aim to nurture intellectual vitality alongside physical care in chronic settings.

Correct Answer: C

Rationale: Family-centered care includes family (A), supports needs (B), improves outcomes (D) 'excludes patient' (C) isn't true, patient central, per model. C's exclusion contradicts focus, like with Mr. Gary's family, making it untrue.

Correct Answer: C

Rationale: Organs harvested before death (C) isn't true donation occurs post-mortem (or brain death), per legal/ethical standards. Age 18 (A) varies, specification (B) is allowed, donor card (D) is legal. C violates donation timing, making it the untrue statement.

Correct Answer: A

Rationale: Leading the team in a care plan is leadership (A) guiding care, per definition. Delegation (B) assigns, literacy (C) understands, QI (D) enhances not leading-specific. A fits directive role, making it correct.

Correct Answer: A

Rationale: Administering against refusal is assault (threat) and battery (unlawful contact).