When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?

Correct Answer: A

Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.

Correct Answer: A

Rationale: The correct answer is A: Avoid alcohol and caffeine. Alcohol and caffeine are diuretics that can increase urine output, leading to fluid loss and potential hypovolemia. This step is crucial in preventing further dehydration. Summary of incorrect choices: B: Increasing milk and dairy products can contribute to fluid intake but does not address the prevention of hypovolemia. C: While dried peas and beans can provide nutrients, they do not specifically address fluid intake or prevention of hypovolemia. D: Avoiding table salt or sodium-containing foods may help in reducing fluid retention but does not directly address fluid intake to prevent hypovolemia.

Correct Answer: A

Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity. B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.

Correct Answer: C

Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image. A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation. B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance. D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.

Correct Answer: D

Rationale: The correct answer is D because in HHNS, the primary goal is to gradually correct dehydration without causing fluid overload. Administering IV fluid slowly helps prevent circulatory overload and collapse. Choice A is incorrect as rapid administration can lead to fluid overload and electrolyte imbalances. Choice B is incorrect as 6L over 24 hours is excessive and can cause fluid overload. Choice C is incorrect as dextrose solution with normal saline is not the ideal fluid replacement for this condition.

Correct Answer: B

Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.

Correct Answer: D

Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.

Correct Answer: B

Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention. Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless. Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand. Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.

Correct Answer: B

Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.