When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:

Correct Answer: A

Rationale: Protecting an unconscious patient from injury is the top priority.

Correct Answer: A

Rationale: The nursing care plan is nursing-centered (A), focusing on nurse-led actions, per planning standards. Rationales support interventions (B) reverses logic, verbal (C) isn't typical, two goals (D) isn't required. A aligns with purpose, making it correct.

Correct Answer: B

Rationale: A low-sodium diet is best for Meniere's syndrome, reducing fluid retention in the inner ear, which mitigates vertigo, tinnitus, and hearing loss flare-ups. High fiber aids digestion, not ear issues; high iodine or low fiber lacks relevance here. Nurses teach this dietary shift to control symptoms, emphasizing sodium's role in fluid balance, supporting long-term management of this chronic condition.

Correct Answer: A

Rationale: Budek's 'Do you think you're crazy?' is reflecting (A), redirecting Rommel's question to explore his feelings or self-perception. Restating (B) repeats verbatim (e.g., 'You think you're crazy?'). Exploring (C) digs deeper (e.g., 'Why do you ask?'). Clarification (D) seeks meaning. Reflecting, per Peplau, fosters self-reflection, apt for Rommel's doubt, making A correct.

Correct Answer: B

Rationale: Disconnecting and draining condensation (B) resolves impedance in oxygen flow from water buildup, maintaining effective delivery. Increasing flow (A) doesn't address it. Replacing tubing (C) is unnecessary if drained. HME (D) is for humidification, not condensation. Draining, per respiratory care, ensures uninterrupted therapy.

Correct Answer: B

Rationale: Questioning a morphine order for pancreatitis exemplifies the client advocate role, where nurses safeguard patient well-being. Morphine can worsen pancreatitis by causing sphincter of Oddi spasm, unlike safer options like meperidine. By challenging this, the nurse protects the client from harm, a duty rooted in ethical codes like the ANA's. Change agents modify behaviors, case managers coordinate, and collaborators work jointly, but advocacy uniquely prioritizes patient safety over compliance. In practice, this might involve consulting the doctor for an alternative, ensuring care aligns with the patient's best interest, a critical nursing responsibility.

Correct Answer: C

Rationale: Implementation is carrying out interventions (C), per nursing process e.g., giving meds. Not identifying (A), setting (B), evaluating (D) action-focused. C best defines implementation's execution, making it correct.

Correct Answer: D

Rationale: Rhytidectomy (facelift) removes excess skin from face and neck.

Correct Answer: A

Rationale: POMR (Problem-Oriented Medical Record) (A) integrates team data per problem, per Weed's system. Traditional (B) and source-oriented (D) separate by discipline. Resource-oriented (C) isn't recognized. A fits interdisciplinary focus, making it correct.