Which of the following assessment finding is typical of extracellular fluid loss?

Correct Answer: C

Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.

Correct Answer: C

Rationale: Critical appraisal in nursing research evaluates evidence quality and relevance post-literature review, ensuring findings guide practice effectively. Asking 'What were the results of each study?' identifies outcomes like reduced infection rates while 'Are the results valid and reliable?' assesses methodological rigor, checking biases or sample issues. 'Will the results improve client care?' gauges practical impact, linking evidence to real-world benefits. 'How many studies were found?' or 'Where were they conducted?' provide context but don't appraise quality. This process filters robust evidence like a study on hand hygiene reducing infections ensuring nurses apply trustworthy, applicable insights. It's a gatekeeper, preventing flawed data from skewing care, and aligns research with nursing's goal of enhancing patient outcomes through science, not just volume or geography.

Correct Answer: C

Rationale: Raising a fist to Mr. Gary is assault (C) intentional threat, per law. Malpractice (A) and negligence (B) are care failures, battery (D) requires touch. C fits the threatening act, making it correct.

Correct Answer: A

Rationale: Adapting to cultural diet is cultural competence (A) diversity respect, per definition. Trust (B) bond, promotion (C) well-being, informatics (D) tech not culture-specific. A fits the nurse's sensitivity to Mr. Gary's needs, making it correct.

Correct Answer: A

Rationale: Potato chips are high in sodium often 120-180 mg per ounce exceeding a 2-gram (2000 mg) daily limit for hypertension, necessitating restriction to control blood pressure. Baked chicken, steamed broccoli, and fresh apples have minimal natural sodium, fitting the diet. Nurses educate clients on hidden sodium in processed snacks, promoting fresh alternatives to reduce cardiovascular strain, aligning with therapeutic goals for long-term health management.

Correct Answer: A

Rationale: Removing the nasal cannula during oral care (A) allows thorough hygiene without interference, briefly tolerable given short duration. Increasing flow (B) is unnecessary. Petroleum jelly (C) isn't for oral care. Mouth breathing (D) isn't needed if removed. Removal, per nursing practice, ensures effective care.

Correct Answer: A

Rationale: Battery is the intentional, unconsented physical contact, like striking a patient, a civil tort with legal repercussions. Negligence is unintentional harm, tort is a broader category, and crime involves criminal law. Nurses avoid battery by obtaining consent, respecting autonomy, as violations breach ethical and legal standards, risking lawsuits or discipline.

Correct Answer: A

Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.

Correct Answer: C

Rationale: Palliative care improves quality of life (C), per its goal managing symptoms, enhancing comfort. It's not hospice-only (A), not cancer-specific (B), and applies beyond irreversible states (D) available at any serious illness stage. C's universal truth aligns with palliative principles, making it correct.