The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?

Correct Answer: C

Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.

Correct Answer: A

Rationale: The correct answer is A: When the patient is resting. This is because the tremor associated with Parkinson's disease is most noticeable when the patient is at rest due to the characteristic "resting tremor" seen in this condition. The tremor tends to lessen or disappear with purposeful movements or activities, making it more difficult to assess during ambulation, meal preparation, or occupational therapy. By observing the patient at rest, the nurse can accurately assess the presence and severity of the tremor, which is a key diagnostic feature of Parkinson's disease. Other answer choices are incorrect because they do not provide the optimal condition for assessing the tremor associated with Parkinson's disease.

Correct Answer: C

Rationale: The correct answer is C: Avoid feminine hygiene products, such as sprays. This is because feminine hygiene products can disrupt the natural balance of vaginal flora, leading to an increased risk of vaginal infections. Tight-fitting synthetic underwear (choice A) can trap moisture and promote bacterial growth. Using bubble bath (choice B) can irritate the genital area and disrupt the pH balance. Restricting daily bathing (choice D) is not recommended as regular hygiene practices are important for preventing infections. In summary, choice C is correct as it promotes maintaining the natural vaginal flora and pH balance to prevent infections, while the other choices can contribute to an increased risk of vaginal infections.

Correct Answer: C

Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.

Correct Answer: A

Rationale: The correct answer is A: Pelvic floor exercises. Pelvic floor exercises help strengthen the muscles that control urination, promoting continence. These exercises can improve bladder control and reduce urinary incontinence post-prostatectomy. Intermittent urinary catheterization (B) may lead to increased risk of infection. Reduced physical activity (C) can weaken pelvic floor muscles, worsening incontinence. Active range of motion exercises (D) do not directly address urinary incontinence.

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: B

Rationale: The correct answer is B: Focusing the patient's immune system exclusively on the tumor. Biologic response modifiers (BRMs) work by enhancing the body's natural defenses to target and attack cancer cells specifically. This approach helps the immune system to recognize and destroy cancer cells while minimizing harm to normal cells. A: Promoting the synthesis and release of leukocytes - This is not the primary mechanism of action for BRMs. While leukocytes play a role in the immune response, BRMs target the immune system's response to tumors. C: Potentiating the effects of chemotherapeutic agents and radiation therapy - While some BRMs may be used in combination with these treatments, their primary mode of action is not to enhance the effects of chemotherapy or radiation therapy. D: Altering the immunologic relationship between the tumor and the patient - This choice is too broad and vague. BRMs specifically aim to direct the immune response towards targeting the tumor cells, rather than altering the overall immunologic relationship

Correct Answer: D

Rationale: The correct answer is D, combining multiple objective measures with subjective measures. This approach provides a comprehensive assessment of the patient's nutritional status by incorporating both quantitative data (objective measures) such as weight, BMI, and laboratory values, as well as qualitative information (subjective measures) like dietary history and appetite changes. By combining these measures, the nurse can obtain a more holistic view of the patient's nutritional status, allowing for better identification of nutritional deficiencies or excesses. This method enhances the accuracy and reliability of the assessment compared to relying solely on one type of measure. Choice A is incorrect because nutritional assessment is crucial even in the presence of chronic disease to address potential malnutrition risks. Choice B is incorrect as the Mini Nutritional Assessment is not intended for pediatric patients but for adults. Choice C is incorrect as using a single tool may not capture the full complexity of the patient's nutritional status.

Correct Answer: A

Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.