Correct Answer: A

Rationale: The correct answer is A: Severe dyspnea. In a tension pneumothorax, air accumulates in the pleural space, increasing pressure in the chest cavity, leading to severe dyspnea due to impaired lung expansion. Extreme agitation (B) is not a typical finding. Tracheal deviation (C) is seen in tension pneumothorax, not always present. Progressive cyanosis (D) may occur but is not as specific as severe dyspnea.

Correct Answer: A

Rationale: The correct answer is A: Severe dyspnea. In a tension pneumothorax, air accumulates in the pleural space, increasing pressure in the chest cavity, leading to severe dyspnea due to impaired lung expansion. Extreme agitation (B) is not a typical finding. Tracheal deviation (C) is seen in tension pneumothorax, not always present. Progressive cyanosis (D) may occur but is not as specific as severe dyspnea.

Correct Answer: C

Rationale: Rationale: Option C is assertive because it clearly communicates the task, priority, and timeframe to the nursing assistant without being aggressive or passive. 1. It states the client's need for assistance with bathing. 2. It clearly instructs the nursing assistant to assist the client immediately. 3. It provides a specific time frame by mentioning that the nursing assistant can go to lunch after finishing the task. Summary: A: This option is passive-aggressive as it guilt-trips the nursing assistant into helping by implying that the nurse will sacrifice their lunch. B: This option is aggressive and threatening, using negative language and ultimatums. D: This option is authoritarian, giving orders without consideration for the nursing assistant's schedule or well-being.

Correct Answer: A

Rationale: The correct answer is A: Assist Ms. C with perineal care. This task can be safely delegated to an Unlicensed Assistive Personnel (UAP) as it involves basic hygiene and does not require specialized medical training. Perineal care includes cleaning the area around the stoma, which is important for maintaining skin integrity and preventing infection. UAPs can be trained to provide this type of care under the supervision of a registered nurse. Choices B, C, and D involve more specialized skills such as proper positioning of the adhesive wafer, measuring colostomy contents, and reapplying a new colostomy bag, which should be performed by a licensed healthcare professional such as a nurse. Delegating these tasks to a UAP could pose a risk to the client's health and safety.

Correct Answer: B

Rationale: The correct answer is B because it promotes client autonomy and informed decision-making. By inviting the client to make a decision after reviewing options, the nurse respects the client's right to self-determination. This approach empowers the client to participate in their own care and make decisions aligned with their values and preferences. It also fosters a collaborative relationship between the nurse and client. Choice A is incorrect because appointing a durable power of attorney does not directly address the client's request for assistance in making a decision about dialysis. Choice C is incorrect as directing the client to have the physician make the decision undermines the client's autonomy. Choice D is incorrect as it does not actively involve the client in the decision-making process.