Correct Answer: B

Rationale: The correct answer is B: Facial paralysis. Bell's palsy is characterized by sudden, temporary weakness or paralysis of the facial muscles on one side of the face. This manifests as drooping of the eyelid and corner of the mouth, difficulty smiling or closing the eye. Tinnitus (A) is ringing in the ears, not a common symptom of Bell's palsy. Pain at the base of the tongue (C) is not a typical manifestation of Bell's palsy. Diplopia (D) is double vision, which is not a primary symptom of Bell's palsy. Therefore, the correct manifestation to address in the plan of care for a patient with Bell's palsy is facial paralysis.

Correct Answer: B

Rationale: The correct answer is B: Acute pain related to misplaced endometrial tissue. This nursing diagnosis should be prioritized because endometriosis commonly presents with severe pelvic pain. Managing pain is crucial for the patient's comfort and quality of life. Anxiety (choice A) is not the priority as pain management takes precedence. Ineffective tissue perfusion (choice C) is not a priority unless the patient is actively hemorrhaging. Excess fluid volume (choice D) is not typically associated with endometriosis. Prioritizing pain management will address the immediate and most distressing symptom for the patient.

Correct Answer: C

Rationale: The correct answer is C because documenting medication administration is critical for patient safety and continuity of care. By documenting the pain medication received, the nurse ensures accurate medication tracking and prevents errors. Choice A is incorrect as it lacks specific, objective information. Choice B is irrelevant to patient care. Choice D is inappropriate and violates patient confidentiality.

Correct Answer: D

Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.

Correct Answer: A

Rationale: The correct answer is A: Ask if he would like you to sit with him while he collects his thoughts. Rationale: 1. Active listening: By offering to sit with him, you show empathy and support his emotional expression. 2. Respect his autonomy: Asking if he would like you to sit allows him to make a choice about what support he needs. 3. Nonjudgmental approach: Sitting with him creates a safe space for him to share his feelings without feeling rushed or judged. Summary: B: Leaving abruptly may make him feel abandoned in a vulnerable moment. C: While spiritual support can be beneficial, it may not address his immediate emotional needs. D: Reassurance is important but may not be as effective as actively listening and offering support in this context.