Which method of data collection will the nurse use to establish a patient’s database?

Correct Answer: C

Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.

Correct Answer: D

Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, skin condition, and overall health status. It provides a comprehensive overview of the patient's current health status and helps in establishing a baseline for further assessments and interventions. Reviewing literature (A) is important for evidence-based practice but does not directly establish a patient's database. Checking orders for tests (B) is essential but does not provide a holistic view of the patient. Ordering medications (D) is a treatment intervention and not a data collection method.

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

Correct Answer: A

Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather patient data through observation, palpation, percussion, and auscultation. It helps in assessing the patient's overall health status, identifying any abnormalities, and establishing a baseline for further care. Reviewing literature (A) helps in evidence-based practice but does not directly collect patient data. Checking orders for tests (B) and ordering medications (D) involve actions based on data collected rather than collecting the data itself.

Correct Answer: C

Rationale: The correct answer is C: To comply with the medication regimen. Teaching the older client with TIA to comply with medication regimen is crucial in preventing further TIAs or strokes. Medications like antiplatelets or anticoagulants are often prescribed to manage TIA. This education empowers the client to actively participate in their own health management. Incorrect choices: A: Not to worry about the symptoms that are part of the normal aging process - This is incorrect as TIA symptoms are not considered a normal part of aging and should not be ignored. B: To admit oneself to a rehabilitation center or a nursing home for rehabilitation - This is incorrect as it is not the primary intervention for managing TIA. D: To observe any changes in the nails and skin - This is incorrect as it is not directly related to managing TIA.

Correct Answer: D

Rationale: The correct answer is D: Aphasia. Mr. Dela Isla's inability to comprehend what the nurse was saying indicates a language impairment, which is characteristic of aphasia. Aphasia is a condition that affects a person's ability to understand or produce language due to damage to the brain's language centers. Insomnia (A) is a sleep disorder, Agnosia (B) is a perception disorder, and Apraxia (C) is a motor planning disorder, none of which align with Mr. Dela Isla's symptoms.

Correct Answer: D

Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.