Correct Answer: D

Rationale: The correct answer is D because it demonstrates active listening and empathy towards the patient's nonverbal cues. By sitting down near the patient and acknowledging his emotions, the nurse opens up a channel for communication and offers support. This approach allows the patient to express his feelings and needs, leading to better understanding and potential resolution of the underlying issue. Other choices are incorrect because: A: Simply documenting the observation does not address the patient's emotional state or provide any opportunity for direct communication. B: Asking another staff member for their perception does not involve the patient directly and may not accurately reflect the patient's emotions. C: Referring to the care plan does not involve the patient in the process and may not address the immediate emotional needs expressed through nonverbal behavior.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Current information on patient's condition change is crucial for effective communication with the primary care provider. 2. This allows the student nurse to provide accurate and up-to-date information for appropriate decision-making. 3. Assessment of vital signs or information on urinary output may be important, but the question specifically focuses on communication about the patient's condition change. 4. Patient's social security number or hospital identification number is not necessary for communicating about the patient's condition change. In summary, choice A is correct as it ensures accurate communication, while the other choices are not directly related to communicating patient's condition change.

Correct Answer: A

Rationale: The correct answer is A. Maintaining eye contact by looking at the client during introductions shows respect by acknowledging the client as an individual and demonstrating active listening. This helps establish trust and rapport. Incorrect choices: B: Avoiding touch may be necessary for infection control, but it does not necessarily show respect for the client. C: Staying 4 to 6 feet away may be necessary for infection control, but it does not demonstrate respect or engagement with the client. D: Briefly conversing about the weather is a social nicety but may not convey the same level of respect and attentiveness as making eye contact.

Correct Answer: C

Rationale: The correct answer is C: Assess for McBurney sign. The McBurney sign is indicative of appendicitis and involves tenderness at McBurney's point in the right lower quadrant. This assessment is crucial for identifying possible appendicitis in a patient presenting with abdominal pain. Assessing for Cullen sign (A) involves bruising around the umbilicus and is associated with intra-abdominal bleeding, not appendicitis. Grey-Turner sign (B) refers to bruising on the flanks and is also indicative of intra-abdominal bleeding. Chvostek sign (D) is a clinical sign of facial muscle twitching and is associated with hypocalcemia. Therefore, assessing for McBurney sign is the most appropriate choice in this scenario to help diagnose appendicitis.

Correct Answer: A

Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety. Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding. Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding. Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.