The nurse is reviewing information about a client and notes the following documentation: 'Client is confused.' The nurse recognizes this information is an example of what?

Correct Answer: C

Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.

Correct Answer: B

Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator. A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery. C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken. D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.

Correct Answer: D

Rationale: The correct answer is D: absence seizures. Barbiturate anticonvulsants are not effective in treating absence seizures because they can worsen this type of seizure by suppressing brain activity. Barbiturates are typically used to treat tonic-clonic seizures and partial seizures, but not absence seizures. Febrile seizures are typically managed without barbiturate anticonvulsants. In summary, barbiturate anticonvulsants are effective in treating partial seizures and tonic-clonic seizures, but not absence seizures or febrile seizures due to their mechanisms of action and potential side effects.

Correct Answer: A

Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.

Correct Answer: D

Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections. - Choice B: Cognitive problems, is not directly related to lymphocyte levels. - Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes. - Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.

Correct Answer: A

Rationale: The correct answer is A because the drug should be resumed when the WBC count falls to 5,000mm3 to ensure the client's safety and efficacy of treatment. This criterion indicates that the client's immune system has recovered sufficiently to tolerate the drug. Choices B, C, and D are incorrect because they do not directly correlate with the client's immune system recovery, which is crucial for drug tolerance. Choice B focuses on the rise in WBC count, not the fall to a specific level. Choice C is related to a cosmetic side effect, not clinical readiness. Choice D is unrelated to immune system recovery.

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.

Correct Answer: B

Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly. A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful. C: Opening the mouth wide while talking is not necessary and may be seen as patronizing. D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.