The nurse observes the client as he walks into the room. What information will this provide the nurse?

Correct Answer: A

Rationale: The correct answer is A because observing the client's gait while walking can provide valuable information about their physical mobility, balance, coordination, and any potential musculoskeletal issues. This assessment helps the nurse determine if the client requires any assistance, mobility aids, or further evaluation by a healthcare provider. Choices B and C are incorrect as observing gait does not directly provide information on personality or psychosocial status. Choice D is incorrect as gait observation is not specifically related to the rate of recovery from surgery. In summary, observing the client's gait is important for assessing physical mobility and identifying potential issues, making it the most relevant choice in this context.

Correct Answer: A

Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.

Correct Answer: C

Rationale: Rationale for Choice C (Correct Answer): 1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm. 2. MS is characterized by demyelination of nerves, leading to visual disturbances. 3. Optic nerve involvement results in vision problems, such as blurred vision. 4. Chiasm involvement can cause visual field deficits and color perception changes. Summary of Other Choices: A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles. B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS. D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.

Correct Answer: C

Rationale: During outcome identification and planning, outcomes are derived from the problem statement of the nursing diagnoses. This is because the problem statement clearly defines the patient's health issue or condition that needs to be addressed, thus guiding the development of specific, measurable, and achievable outcomes. The defining characteristics (choice A) describe the signs and symptoms of the health problem but do not directly lead to outcome identification. The related factors (choice B) represent the potential causes or contributing factors to the health problem and are not used to derive outcomes. The database (choice D) consists of the patient's health history, assessment data, and laboratory findings, which are essential for diagnosing but do not directly determine outcomes. Therefore, the correct answer is C as it directly informs the outcomes to be achieved.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to reflect on the potential causes of their fatigue, leading to a more detailed and insightful response. This open-ended question allows the patient to explore various factors contributing to their fatigue, such as lifestyle habits, medical conditions, or emotional stressors. Choice A focuses on stress, which may not be the primary cause of fatigue for the patient. Choice C is too specific and may not uncover other relevant information. Choice D assumes that sleep duration is the sole factor contributing to fatigue, neglecting other possible causes. Overall, choice B facilitates a more comprehensive discussion and helps the nurse gather valuable information to address the patient's concerns effectively.

Correct Answer: C

Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.

Correct Answer: B

Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.

Correct Answer: C

Rationale: The correct answer is C: Paroxysms or shortness of breath. Asthma is characterized by episodes of wheezing, coughing, chest tightness, and shortness of breath, known as paroxysms. This symptom is caused by inflammation and constriction of the airways in response to triggers such as allergens or irritants. A: Production of abnormally thick, sticky mucus in lungs is more indicative of conditions like cystic fibrosis, not asthma. B: Faulty transport of sodium in lung cells is associated with conditions like cystic fibrosis, not asthma. D: Altered electrolyte balance in the sweat glands is a symptom of cystic fibrosis, not asthma. In summary, paroxysms or shortness of breath is a key sign of asthma due to airway inflammation and constriction, distinguishing it from the other choices that are more indicative of cystic fibrosis.

Correct Answer: D

Rationale: The correct answer is D: Stapedectomy. This procedure is used to correct otosclerosis by removing the stapes bone and replacing it with a prosthetic device. This restores normal hearing by allowing sound waves to travel through the ear properly. Myringotomy (A) is a procedure to drain fluid from the middle ear, not to correct otosclerosis. Mastoidectomy (B) is the removal of infected mastoid air cells, not related to otosclerosis. Myringoplasty (C) is a surgical procedure to repair a perforated eardrum, not used for otosclerosis. Stapedectomy is the most appropriate choice for correcting otosclerosis as it directly addresses the abnormal bone growth in the middle ear.