What is the nurse’s firstaction?

Correct Answer: B

Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.

Correct Answer: C

Rationale: The correct answer is C: Time-lapsed assessment. This type of assessment involves comparing baseline data with new data collected at a later time to evaluate changes in the client's condition. In this scenario, the nurse is reassessing the client a month later to determine if there have been any changes that require adjustments to the care plan. A: Comprehensive assessment is an in-depth assessment done initially to gather detailed information about the client's overall health status. B: Focused assessment is done to gather specific information related to a particular problem or issue. D: Emergency assessment is performed in urgent situations to quickly identify and address life-threatening conditions.

Correct Answer: A

Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.

Correct Answer: C

Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients. Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf. Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image. Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery. In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.

Correct Answer: C

Rationale: The correct answer is C because it does not provide a specific, measurable outcome. It is vague and subjective, making it difficult to assess and track progress. In contrast, choices A, B, and D are all specific, measurable, and time-bound goals, making them more effective for evaluating client outcomes. Choice A specifies the amount of fluid intake and the time frame, choice B sets a clear deadline for demonstrating a skill, and choice D outlines a specific task to be completed upon discharge. Therefore, C is the correct answer as it lacks the clear criteria needed for effective outcome evaluation.