Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in nursing clinical decision-making. In this scenario, the nurse considers the patient's self-reported information (time of last dressing change and observation of old and new drainage) as key data points to validate the need for changing the wound dressing. This aligns with the principles of evidence-based practice and ensures that the decision is based on accurate and relevant information. Choices B, C, and D are incorrect because they do not involve the systematic validation of data to inform the nursing decision-making process. Choice B relies on family input rather than objective data, Choice C jumps to a treatment decision without confirming the underlying cause, and Choice D does not involve validating the patient's reported symptom before taking action.

Correct Answer: C

Rationale: The correct answer is C: Autoantibodies. In Hashimoto's thyroiditis, the immune system mistakenly attacks the thyroid gland by producing autoantibodies against thyroid proteins such as thyroglobulin and thyroid peroxidase. These autoantibodies lead to inflammation and destruction of thyroid tissue. Antigen-antibody complexes (choice A) are not the main mechanism in Hashimoto's thyroiditis. Viral (choice B) and bacterial infections (choice D) do not directly cause autoimmune destruction of the thyroid in this condition. Autoantibodies targeting the thyroid gland are the key pathogenic factor in Hashimoto's thyroiditis.

Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.

Correct Answer: A

Rationale: The correct answer is A: "Would you like to talk to a psychologist about your thoughts and feelings?" This response acknowledges the client's emotional distress and offers professional support. A psychologist can provide counseling and help the client explore their feelings and concerns about end-of-life decisions. Choice B is incorrect because it assumes the client's spiritual beliefs are the primary concern, neglecting the emotional and psychological aspects. Choice C involves more people in the decision-making process without addressing the client's individual needs. Choice D is dismissive and does not offer any support or explore the client's feelings further. In summary, choice A is the best response because it prioritizes the client's emotional well-being and offers appropriate support through professional counseling.

Correct Answer: B

Rationale: The correct answer is B because in a normal Rinne test, air conduction is heard longer than bone conduction in both ears. This is due to the fact that air conduction involves the transmission of sound waves through the external auditory canal, middle ear, and inner ear, which is more efficient than bone conduction where the sound waves are transmitted directly to the inner ear through the bones of the skull. Therefore, when the tuning fork is placed on the mastoid bone (bone conduction) and then moved next to the ear (air conduction), the sound should be heard longer through air conduction. Choice A is incorrect because normal auditory acuity does not necessarily mean equal perception in both ears. Choice C is incorrect as bone conduction should be heard shorter than air conduction in a normal Rinne test. Choice D is incorrect as the test does not determine which ear perceives sound better, but rather the difference in duration between air and bone conduction.