Correct Answer: D

Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.

Correct Answer: B

Rationale: The correct answer is B because a client's medical history of allergy to iodine or seafood is crucial for urinary diversion assessment to prevent potential adverse reactions during procedures involving contrast media or seafood-based medications. It is essential to ensure the client's safety and avoid any allergic reactions. Choice A is incorrect because assessing sexual function is not directly related to urinary diversion assessment. Choice C is also incorrect as urinary diversion does not typically affect nervous control. Choice D is irrelevant to the assessment of a client undergoing urinary diversion.

Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications. Summary of why other choices are incorrect: B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario. C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions. D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.

Correct Answer: D

Rationale: The correct answer is D - Check for a gag reflex before allowing the patient to drink. This is important after a bronchoscopy to prevent aspiration. Step 1: Assessing gag reflex ensures the patient can protect their airway. Step 2: Aspiration risk is high post-bronchoscopy due to sedation and possible throat numbness. Step 3: Allowing fluids without confirming gag reflex can lead to aspiration pneumonia. Other choices are incorrect. A: Ordering a meal immediately is inappropriate after NPO period. B: Encouraging fluids without assessing gag reflex may lead to aspiration. C: Monitoring consciousness is important but not directly related to post-bronchoscopy care.