What is the primary purpose of using measurable client outcomes during the nursing process?

Correct Answer: B

Rationale: The primary purpose of using measurable client outcomes during the nursing process is to evaluate the effectiveness of nursing interventions. This is crucial in determining whether the care provided has led to the desired outcomes for the client's health. By measuring outcomes, nurses can assess if the interventions are successful, make any necessary adjustments to the care plan, and ensure optimal patient outcomes. Choice A is incorrect because diagnosing client conditions accurately is not the primary purpose of using measurable client outcomes; it is more related to the initial assessment phase. Choice C is incorrect because prioritizing nursing diagnoses effectively is an important aspect of the nursing process, but it is not the primary purpose of using measurable client outcomes. Choice D is incorrect because while documentation in the client's health record is important, it is not the primary purpose of using measurable client outcomes.

Correct Answer: A

Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting. Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.

Correct Answer: A

Rationale: The correct answer is A (5 to 10 mcg/ml) because this range is typically considered therapeutic for phenytoin (Dilantin) for seizure control. Levels below 5 mcg/ml may be subtherapeutic, leading to inadequate seizure control. Levels above 10 mcg/ml can increase the risk of toxicity. Choices B, C, and D are incorrect because they are outside the optimal therapeutic range, leading to either ineffective treatment (B, C) or an increased risk of adverse effects (D). Monitoring drug levels helps ensure the medication's effectiveness while minimizing side effects.

Correct Answer: B

Rationale: The correct answer is B: Compatible blood and tissue types. This is crucial to minimize the risk of rejection and ensure a successful transplant. Matching blood and tissue types help prevent the recipient's immune system from attacking the new organ. Blood relationship (A) is not as important as compatibility. Sex and size (C) are important considerations for certain transplants but not the most crucial factor. Need (D) is relevant but does not outweigh the importance of compatibility to ensure a successful transplant.

Correct Answer: B

Rationale: The correct answer is B: Severe tenderness and swelling in the scrotum. Epididymitis is characterized by inflammation of the epididymis, causing symptoms such as severe tenderness and swelling in the scrotum. Choice A is incorrect as burning and pain on urination are more indicative of a urinary tract infection. Choice C, foul-smelling ejaculate and severe scrotal swelling, is not commonly associated with epididymitis. Choice D, foul-smelling urine and pain on urination, may indicate a urinary tract infection but are not specific to epididymitis.

Correct Answer: B

Rationale: The correct answer is B: To prevent respiratory obstruction. An ice collar is used to reduce swelling and inflammation, which can help prevent the abscess from compressing the airway and causing respiratory obstruction. This is crucial in cases of peritonsillar abscess to ensure the client's airway remains patent. Choices A, C, and D do not directly address the primary concern of preventing respiratory obstruction in this context.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.

Correct Answer: C

Rationale: The correct answer is C: Tactile agnosia. When assessing a client with a parietal lobe brain tumor, the nurse would expect to assess for tactile agnosia as the parietal lobe is responsible for processing sensory information, including touch and spatial awareness. Tactile agnosia is the inability to recognize objects by touch. This impairment is commonly associated with parietal lobe lesions. Short-term memory impairment (A) is more commonly associated with temporal lobe lesions. Seizures (B) are more commonly associated with frontal lobe lesions. Contralateral homonymous hemianopia (D) is associated with occipital lobe lesions. In summary, the parietal lobe tumor would likely manifest as tactile agnosia due to its role in sensory processing, making it the most relevant assessment finding in this scenario.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.