Correct Answer: A

Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows: 1. The patient has a standing order for acetaminjson for headache relief. 2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours. 3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs. Summary: - Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order. - Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision. - Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.

Correct Answer: C

Rationale: Correct Answer: C - Diffusion Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.

Correct Answer: C

Rationale: The correct answer is C. Hormonal imbalances are the primary cause of BPH in aging males. As men age, testosterone levels decrease and estrogen levels may increase relative to testosterone, leading to prostate gland growth. This is why hormonal imbalances are more likely the cause of BPH in older males. Explanation of other choices: A: Chronic infection of the urinary tract does not directly cause BPH, although it can lead to similar symptoms such as urinary frequency and urgency. B: Chronic cigarette smoking is not a direct cause of BPH, although it can contribute to overall prostate health and exacerbate symptoms. D: Chronic obstruction of the bladder due to stone is a separate condition from BPH, although it can cause similar urinary symptoms.

Correct Answer: D

Rationale: Step 1: A goal should be measurable to track progress effectively. Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome. Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound. Step 4: Other choices lack the specificity and measurability required for a clear goal. Step 5: Choice A talks about restriction, which is not directly related to understanding a goal. Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal. Step 7: Choice C is vague and lacks the specificity of a measurable outcome.

Correct Answer: A

Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.