Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?

Correct Answer: D

Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.

Correct Answer: D

Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

Correct Answer: C

Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis. A: Hyperventilation would lead to respiratory alkalosis, not acidosis. B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis. D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis. In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.

Correct Answer: B

Rationale: The correct answer is B because rehabilitation plans should be considered and planned for early in Mr. Gabatan's care to ensure the best outcomes. By addressing rehabilitation early, healthcare professionals can tailor interventions to his specific needs, promote independence, and prevent complications. This proactive approach enhances Mr. Gabatan's quality of life and functional abilities. Choices A, C, and D are incorrect: A: Leaving rehabilitation plans solely up to Mr. Gabatan and his family may not ensure comprehensive care and could lead to delays or inadequate support. C: Assuming Mr. Gabatan will return to former activities without proper rehabilitation assessment and planning overlooks potential limitations and needs. D: Assuming Mr. Gabatan will not be able to work again without proper rehabilitation evaluation and interventions may limit his potential for recovery and independence.

Correct Answer: B

Rationale: Step 1: IV morphine is the correct choice as it is a potent analgesic and has a rapid onset of action to reduce shortness of breath (SOB) in a crisis situation. Step 2: Oral cortisone (A) is not suitable for quick relief of SOB as it has a slower onset of action. Step 3: IM meperidine (C) is an opioid analgesic but not commonly used for managing SOB in end-stage respiratory disease. Step 4: IV propranolol (D) is a beta-blocker and not indicated for immediate relief of SOB in a crisis situation.

Correct Answer: B

Rationale: The correct answer is B: Eat a diet high in protein and calories to optimize tissue repair. Rationale: 1. Protein is essential for tissue repair and healing, which can help counteract the effects of radiation therapy on the skin and swallowing function. 2. Calories are necessary for energy to support the body's healing processes during radiation therapy. 3. A diet high in protein and calories can help maintain overall nutritional status and promote recovery. Incorrect Choices: A: Washing the radiation site vigorously can further irritate the skin, leading to more complications. C: Cool compresses may not be suitable for radiation-induced skin reactions and may not address the underlying issue of dysphagia. D: Drinking warm fluids may not directly address the need for optimal tissue repair and healing.

Correct Answer: B

Rationale: The correct answer is B because having the patient rate her fatigue on a scale allows for a subjective assessment directly from the patient, providing valuable insight into the severity and impact of fatigue on her daily life. This approach considers the patient's perspective, which is crucial in understanding her experience and tailoring interventions. Choice A (observing activity level) may not accurately capture the subjective experience of fatigue. Choice C (monitoring vital signs) does not directly assess fatigue but rather general health status. Choice D (monitoring hemoglobin and hematocrit values) can indicate anemia but may not fully capture the patient's fatigue experience.

Correct Answer: D

Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.