What is the step of the nursing process that includes data collection through health history taking, physical examination, and interview?

Correct Answer: D

Rationale: The correct answer is D: Assessment. Assessment is the first step in the nursing process where data is collected through health history, physical examination, and interview. This step helps in identifying the patient's needs and health problems. Planning (A) comes after assessment and involves setting goals and creating a care plan. Diagnosis (B) is the step where nursing diagnoses are formulated based on the assessment data. Evaluation (C) is the final step where the effectiveness of the care plan is assessed. In summary, Assessment is the initial step focused on data collection, making it the correct choice.

Correct Answer: A

Rationale: The correct answer is A (Broccoli, oranges, dark greens) because these foods are high in soluble fiber, antioxidants, and plant sterols which are known to help lower cholesterol levels. Broccoli contains fiber that binds to cholesterol in the gut, oranges are rich in vitamin C and fiber, and dark greens like spinach and kale are packed with antioxidants and fiber. Option B (Fiber-rich foods) is partially correct as fiber can help reduce cholesterol levels, but it is not as specific as the foods mentioned in option A. Option C (Increase intake of omega-3 fatty acids) is not directly related to lowering cholesterol, although omega-3s have other health benefits. Option D (Eliminate fat-rich foods) is not ideal as not all fats are bad for cholesterol, and some healthy fats like those found in avocados and nuts can actually improve cholesterol levels.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In ARDS, the primary issue is hypoxemia due to impaired gas exchange in the lungs. Administering oxygen helps to increase the oxygen levels in the blood, improving oxygenation to vital organs. Corticosteroids (B) are not indicated as they have not shown consistent benefit in ARDS treatment. Bronchodilators (C) are not effective as ARDS is not primarily a bronchoconstrictive disorder. Applying an ice pack to the chest (D) is not relevant and will not address the underlying hypoxemia. Administering oxygen is the most effective and essential intervention to correct hypoxemia in ARDS.

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.

Correct Answer: B

Rationale: The correct answer is B: To monitor the amount of airway obstruction. A peak flow meter is used to measure how well the patient can exhale air from the lungs, indicating the degree of airway obstruction in conditions like asthma. By monitoring peak flow readings, the nurse can assess the severity of the patient's asthma and adjust treatment accordingly. Choices A, C, and D are incorrect: A: To measure the amount of oxygen in the blood - This is the function of a pulse oximeter, not a peak flow meter. C: To measure the frequency of inhaler use - This is not the primary purpose of a peak flow meter, which is specifically used to monitor airway obstruction. D: To track blood glucose levels - This is the function of a glucometer, not a peak flow meter used for asthma management.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. In chronic heart failure, the heart cannot pump blood effectively, leading to fluid buildup in the lungs causing pulmonary edema. Monitoring for signs such as shortness of breath, wheezing, and crackles can help prevent respiratory distress. Incorrect choices: A: Hypoglycemia - Not directly related to chronic heart failure. B: Hyperkalemia - Can occur in heart failure but not a primary complication to monitor for. D: Anemia - Can be a consequence of chronic heart failure but not a primary complication to monitor for.

Correct Answer: B

Rationale: The correct answer is B: a set of rules. Novice nurses rely on established guidelines and protocols to make decisions as they lack the experience to rely solely on intuition or journal articles. Rules provide structure and consistency in decision-making, reducing the margin of error. Intuition (choice A) may not be reliable without prior experience. Journal articles (choice C) can be overwhelming and may not directly apply to the specific situation. Advice from supervisors (choice D) can be helpful but may not always be readily available, and it's important for novice nurses to develop their own decision-making skills.