What is the primary function of a written nursing care plan?

Correct Answer: D

Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.

Correct Answer: B

Rationale: The highest source of calcium among the given choices is the 3 oz of canned salmon. This is due to the presence of bones in canned salmon, which are rich in calcium. The other options, including 1 cup of carrot strips, 1 plain baked potato, and 1 cup of chopped chicken breast, do not contain as much calcium due to the nature of their composition and lack of bone content.

Correct Answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

Correct Answer: B

Rationale: The best choice for a pruritus (itching) patient is a colloidal (oatmeal) bath, as it is known for its soothing effect on itchy, irritated skin. Saline, water, and sodium bicarbonate baths may not provide the same level of relief for pruritus. The nursing care should involve comprehensive assessments and appropriate interventions to optimize patient outcomes. In this case, a colloidal bath is the most suitable intervention for a patient experiencing pruritus.

Correct Answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

Correct Answer: A

Rationale: In psychological terms, a 'Crisis' refers to a state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms. This is different from 'Mental Illness' (Choice C) which is a more general term for a wide range of mental health conditions that affect mood, thinking and behavior. 'Mental Health' (Choice B) is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Finally, 'Stress' (Choice D) is a state of mental or emotional strain or tension resulting from adverse or demanding circumstances, but it does not necessarily disrupt equilibrium to the extent that usual coping mechanisms are ineffective, unlike 'Crisis'.

Correct Answer: C

Rationale: The correct answer is C, frequent urination. As people age, they may experience physiological changes that can lead to an increased frequency of urination. This is due to a decrease in bladder capacity and increased bladder irritability, which are normal age-related changes. On the contrary, the sense of taste (Choice A) and appetite (Choice B) often decrease with age, not increase. As for Choice D, the lens of the eye actually thickens with age, not thins, leading to conditions like presbyopia. Therefore, Choices A, B, and D are incorrect.

Correct Answer: D

Rationale: The correct answer is 'D: Advanced age of the client.' Age can be a significant obstacle in communication due to factors such as hearing loss, cognitive decline, or memory issues, which all can hamper effective communication. Choices A, B, and C, while they may present challenges in communication, are not directly related to age and its influence on communication, making them incorrect. The issues presented by not using universally accepted abbreviations, incorrect grammar, and poor handwriting can be resolved through clarification, education, or the use of alternative communication methods, unlike the difficulties that can arise from advanced age.

Correct Answer: B

Rationale: Hypokalemia, a condition characterized by low levels of potassium in the blood, is reflected in an ECG by a widening QRS Complex and a U wave. This is because potassium plays a key role in the electrical activity of the heart, and its deficiency can lead to abnormalities in the heart's rhythm as represented by these specific changes on the ECG. Choice A is incorrect as tall T waves and pathologic Q waves are more commonly associated with hyperkalemia or myocardial infarction, respectively, rather than hypokalemia. Choices C and D are also incorrect as they do not accurately reflect the ECG changes caused by hypokalemia.