When recording blood pressure, the sounds which can be heard with a stethoscope placed over the artery is termed as:

Correct Answer: D

Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.

Correct Answer: B

Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.

Correct Answer: D

Rationale: The adrenocortical response, triggered by fasting (NPO status), activates stress hormones like cortisol and aldosterone, conserving resources during deprivation. Decreased urine output results from aldosterone's promotion of sodium and water reabsorption in the kidneys, maintaining fluid volume and blood pressure. This adaptation counters the stress of fasting, ensuring homeostasis. Low blood pressure would oppose this, as the response aims to stabilize circulation, not reduce it. Warm, dry skin isn't typical; stress might cause cool, clammy skin from vasoconstriction, but fasting alone doesn't dictate this. Decreased serum sodium levels contradict aldosterone's sodium-retaining effect, which elevates or stabilizes sodium. Decreased urine output aligns with the body's conservation mechanism, making it the expected physiological response in this scenario, critical for nurses to recognize during patient monitoring.

Correct Answer: A

Rationale: Self-regulation in critical thinking involves monitoring and improving one's performance through reflection on experiences, identifying strengths and weaknesses. A nurse reflecting on past care to enhance future practice exemplifies this e.g., adjusting communication after a patient misunderstanding. Analysis breaks down data (e.g., lab results), not necessarily reflecting on personal performance. Inference draws conclusions from evidence (e.g., diagnosing from symptoms), not self-improvement. Explanation justifies actions (e.g., why a drug was given), not introspective growth. Self-regulation's focus on self-assessment and correction aligns with the nurse's reflective process, fostering continuous professional development, a vital skill in nursing for adapting to challenges and ensuring high-quality, patient-centered care over time.

Correct Answer: A

Rationale: Nursing's paradigm comprises person (client), health (well-being goal), environment/situation (context), and nursing (practice) a metaparadigm unifying theories like Nightingale's or Watson's. This defines nursing's scope, focusing on client care holistically. Concepts, theory, health, and environment are abstract, not a complete paradigm missing 'person' and 'nursing.' Health, person, environment, and theory swap 'nursing' for 'theory,' confusing framework with product. Nurses, physicians, models, and needs mix roles and tools, not core concepts. The person, health, environment, and nursing quartet encapsulates nursing's domain, guiding practice and research comprehensively.