Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

Correct Answer: A

Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.

Correct Answer: C

Rationale: The correct answer is C: Tactile agnosia. When assessing a client with a parietal lobe brain tumor, the nurse would expect to assess for tactile agnosia as the parietal lobe is responsible for processing sensory information, including touch and spatial awareness. Tactile agnosia is the inability to recognize objects by touch. This impairment is commonly associated with parietal lobe lesions. Short-term memory impairment (A) is more commonly associated with temporal lobe lesions. Seizures (B) are more commonly associated with frontal lobe lesions. Contralateral homonymous hemianopia (D) is associated with occipital lobe lesions. In summary, the parietal lobe tumor would likely manifest as tactile agnosia due to its role in sensory processing, making it the most relevant assessment finding in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.

Correct Answer: C

Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.

Correct Answer: A

Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.

Correct Answer: C

Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.

Correct Answer: A

Rationale: The correct answer is A: To stimulate bone growth. Estrogen and progesterone are hormones that play a crucial role in maintaining bone density and promoting bone growth. In postmenopausal women or individuals with conditions like aplastic anemia, bone health can be compromised. Estrogen helps in preventing bone loss and maintaining bone strength, while progesterone also contributes to bone formation. Therefore, in this scenario, these medications are likely prescribed to help improve bone health in the woman with aplastic anemia. Incorrect choices: B: Estrogen and progesterone do not directly enhance sodium and potassium levels. C: Estrogen and progesterone do not regulate fluid balance absorption directly. D: Estrogen and progesterone do not specifically promote utilization and storage of fluids.

Correct Answer: A

Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.