When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?

Correct Answer: C

Rationale: The nurse should assess that the diet of the Hispanic family, which consists mainly of vegetables, legumes, and starches, may provide sufficient amino acids. While this diet may lack animal sources of protein commonly found in meat and milk, plant-based foods like legumes and grains can complement each other to provide all essential amino acids necessary for protein synthesis in the body. This combination of foods essentially forms a complete protein source, supporting overall nutritional needs. It's important for the nurse to recognize the potential nutritional value in the diet and offer education on balanced meal planning to ensure adequate protein intake for the family. The assessment should focus on the overall nutrient adequacy and not solely on the presence of specific food items.

Correct Answer: C

Rationale: Compatibility between a donor and recipient of blood is determined by testing for compatibility of blood types. The most common blood typing systems are ABO and Rh. In compatibility testing, both the donor and recipient blood samples are mixed in the laboratory. If there is no clumping (agglutination) or hemolysis (rupture of red blood cells) observed when the samples are mixed, then the donor and recipient are considered compatible. Clumping or hemolysis indicates an incompatible blood transfusion, which can lead to serious complications like agglutination, blood clotting, or immune responses. Therefore, the absence of clumping or hemolysis is a key indicator of blood compatibility in transfusion medicine.

Correct Answer: D

Rationale: Presence of intratumoral calcifications may warrant biopsy to rule out other diagnoses.

Correct Answer: A

Rationale: In developmental hip dysplasia (DDH), one knee appearing lower than the other when both legs are flexed indicates a possible dislocated hip joint or hip dysplasia. This finding is known as the Galeazzi sign and is often used as a clinical indicator for DDH in newborn infants. It suggests a discrepancy in leg lengths due to hip instability or malformation. Therefore, this sign is important in helping to diagnose DDH and initiating appropriate interventions early on.

Correct Answer: B

Rationale: In acute bronchitis, the highest priority in the teaching plan should focus on preventing the spread of infection. Washing hands frequently can help reduce the risk of spreading the infection to others or introducing new germs that could worsen the client's condition. Proper hand hygiene is one of the most important ways to prevent the transmission of respiratory infections, like bronchitis, by reducing the number of pathogens on the hands. This measure is important not only for the client's well-being but also for the health of those in close contact with the client.