The physician has ordered a 24-hour urine collection for a client. Which action by the nurse will ensure proper collection of the specimen?

Correct Answer: C

Rationale: Checking intake and output during a 24-hour urine collection ensures accuracy by tracking fluid balance ice is for specific tests (e.g., catecholamines), discarding the first void starts the clock (not skips it), and catheterization isn't routine. Nurses monitor this, ensuring valid results for diagnostic purposes like renal function.

Correct Answer: A

Rationale: Vaccines in pregnancy balance maternal-fetal safety. Rubella vaccine (choice A), a live attenuated virus, is contraindicated due to theoretical risks of congenital rubella syndrome if the virus crosses the placenta, though no cases are definitively linked. Diphtheria (choice B) and tetanus (choice C) vaccines, as inactivated toxoids (e.g., Td), are safe and recommended to protect mother and newborn. Hepatitis B vaccine (choice D), an inactivated subunit vaccine, poses no fetal risk and is given if the mother is at risk. A is correct because rubella's live nature excludes it from routine prenatal use. Nurses must counsel pregnant women on vaccine safety, ensuring tetanus protection while avoiding live vaccines like rubella to safeguard fetal development.

Correct Answer: C

Rationale: Developmental milestones flag delays if unmet. Walking at 12 months (choice A) is average; delay to 18 months is still normal. Single words at 12 months (choice B) vary (9-18 months), not an immediate red flag. Social smile by 3 months (choice C, typically 6-8 weeks) is critical; absence by 3 months suggests autism or neurological issues, a major concern. Vocalization at 2 months (choice D, cooing) is expected, but delay isn't as alarming as smile absence. C is correct, as it's a key early red flag. Nurses refer for evaluation, ensuring timely intervention.

Correct Answer: D

Rationale: Wrist drop is inability to extend the wrist. Axillary nerve (choice A) affects shoulder, not wrist. Ulnar nerve (choice B) impacts hand sensation/movement, not extension. Median nerve (choice C) controls forearm flexors. Radial nerve (choice D) innervates wrist extensors; injury (e.g., humeral fracture) causes wrist drop. D is correct, per anatomy. Nurses assess grip, apply splints, and support rehab, aiding recovery.

Correct Answer: B

Rationale: Hildegard Peplau (B) defined the nurse-patient relationship in four stages: Orientation (meeting and trust-building), Identification (role clarity), Exploitation (using resources for goals), and Resolution (termination). Roy (A) focuses on adaptation, Rogers (C) on unitary humans, and Travelbee (D) on human-to-human connection, none using these exact stages. Peplau's interpersonal theory is foundational in nursing, aligning with the described phases, making B correct.