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: C

Rationale: The correct answer is C: Developing nursing diagnoses before completing the database. This is incorrect because developing nursing diagnoses should be based on a comprehensive assessment and analysis of the patient's data. By developing nursing diagnoses before completing the database, the new nurse may overlook important information that could impact the accuracy of the diagnosis and subsequent care plan. Choice A (intravenous antibiotics) is incorrect because assigning a nursing diagnosis of Risk for infection for a patient on IV antibiotics is a common and appropriate practice given the increased risk of infection associated with invasive procedures. Choice B (Completing an interview and physical examination before adding a nursing diagnosis) is incorrect because nursing diagnoses should be developed based on the data collected during the assessment process, which includes the interview and physical examination. It is not necessary to complete the entire assessment before assigning a nursing diagnosis. Choice D (Including cultural and religious preferences in the database) is incorrect because while it is important to consider cultural and religious preferences in care planning, this does not directly relate to the

Correct Answer: B

Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.

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: B

Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment. A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates. C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society. D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.

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: C

Rationale: The correct initial action is to choose C: Ask the patient about the facial grimacing with movement. This is important as the patient's non-verbal cues (facial grimacing) contradict their verbal pain report. By directly addressing the discrepancy, the nurse can gather more accurate information about the patient's pain experience and potentially identify any underlying issues causing the discrepancy. Proceeding to the next patient's room (A) without addressing the discrepancy would neglect the patient's needs. Assuming the patient does not want pain medicine (B) based solely on the verbal report without further assessment is premature. Administering pain medication (D) without clarifying the situation may lead to inappropriate or ineffective treatment. Therefore, option C is the most appropriate initial action to ensure comprehensive and individualized patient care.