The primary source of data during the assessment phase of the nursing process is:

Correct Answer: A

Rationale: The correct answer is A: Patient. During the assessment phase of the nursing process, the primary source of data should be the patient themselves. This is because the patient can provide firsthand information about their symptoms, medical history, and current condition. Relying on the patient ensures that the assessment is comprehensive and accurate. Family members (B) may provide valuable information, but it is secondary to the patient's own input. Nurse's notes (C) are important for documenting observations and interventions but should not be the primary source of data during the assessment phase. Lab results (D) are also essential but are typically obtained after the assessment phase to supplement the information gathered directly from the patient.

Correct Answer: A

Rationale: The correct answer is A: Bone fracture. Elderly females with osteoporosis have weakened bones, making them more susceptible to fractures. Teaching about this major complication is crucial for preventing falls and fractures. Loss of estrogen (B) and negative calcium balance (C) are contributing factors to osteoporosis but do not directly represent a major complication. Dowager's hump (D) is a visible sign of osteoporosis but is not a major complication in itself. It is important to focus on preventing bone fractures to ensure the patient's safety and quality of life.

Correct Answer: D

Rationale: The correct answer is D because if a person is coughing forcefully, it indicates that their airway is not completely blocked. Intervening with abdominal thrusts in this scenario can potentially make the situation worse by causing the object to become more lodged. Therefore, staying with the person but not intervening allows them to continue coughing and attempting to clear the obstruction themselves. Monitoring the person closely is important in case the situation worsens and they become unable to breathe or speak. The other choices are incorrect because they involve performing abdominal thrusts, which is not recommended when the person is able to cough effectively.

Correct Answer: B

Rationale: The correct answer is B: The 89-year-old client with end-stage right-sided heart failure blood pressure of 78/50 mm Hg and a “do not resuscitate” order. This client should be assessed first because of the critically low blood pressure and the "do not resuscitate" order, indicating the client's preference for end-of-life care. This situation requires immediate intervention and communication with the healthcare team to ensure the client's wishes are respected. Choice A is stable with heart failure but has normal vital signs. Choice C is receiving I.V. heparin for thrombophlebitis, which is important but not immediately life-threatening. Choice D has new-onset atrial fibrillation but is stable and receiving appropriate treatment. Prioritizing based on acuity and potential for deterioration is crucial in nursing practice.

Correct Answer: B

Rationale: The correct answer is B: Young children. Nutrition education should not target young children because they are not responsible for making their own food choices. Educating children directly may not be as effective as targeting parents or caregivers who are responsible for providing nutritious meals. Food handlers, food service people, and mothers are appropriate targets for nutrition education as they play direct roles in food preparation and decision-making. It is important to prioritize education for those who have the most influence on food choices in order to promote healthy eating habits effectively.