Which step of the nursing process includes data collection by health history, physical examination, and interview?

Correct Answer: D

Rationale: In the nursing process, assessment is the step that involves the systematic collection of data through health history, physical examination, and interviews. This step is crucial as it forms the foundation for all further nursing interventions and decisions. Through assessment, nurses gather essential information about the patient's current health status, which then guides the subsequent steps of the nursing process. Option A, Planning, is incorrect because planning comes after assessment. Once data has been collected through assessment, the nurse then moves on to planning interventions and setting goals based on the assessment findings. Option B, Diagnosis, is incorrect because diagnosis follows the assessment phase. In the nursing process, diagnosis involves analyzing the data collected during assessment to identify the patient's health problems and needs. Option C, Evaluation, is incorrect because evaluation occurs after interventions have been implemented. Evaluation involves assessing the patient's response to the interventions and determining the effectiveness of the care provided. Understanding the sequential nature of the nursing process is essential for nurses to provide comprehensive and effective care to their patients. By correctly identifying assessment as the step involving data collection, nurses can ensure they have a solid foundation on which to base their subsequent nursing actions.

Correct Answer: C

Rationale: In the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's blood pressure (Option C). This is because thrombolytic therapy carries the risk of bleeding, including intracerebral hemorrhage. Elevated blood pressure can exacerbate this risk by increasing the chances of bleeding. Therefore, controlling blood pressure is crucial to reduce the risk of hemorrhagic transformation post-thrombolytic therapy. Option A, Pulse, is not the primary focus because while monitoring pulse is important, it is not the immediate concern post-thrombolytic therapy for stroke. Respirations (Option B) and Temperature (Option D) are also not the primary goals in this context. Educationally, understanding the rationale behind monitoring and controlling blood pressure in the acute phase after thrombolytic therapy for ischemic stroke is vital for nursing and healthcare students. It emphasizes the critical role of maintaining hemodynamic stability to prevent complications and optimize patient outcomes in stroke care. This knowledge guides clinical decision-making and promotes safe and effective patient care.

Correct Answer: D

Rationale: The correct answer is option D) Distance walked. In the context of assessing endurance using the Six-Minute Walk Test, measuring the distance walked is the most appropriate variable for determining the patient's endurance level. Distance walked is a direct and objective measure of how far the patient can walk in six minutes, reflecting their physical endurance capacity. It provides a clear and quantifiable result that can be easily tracked and compared over time to monitor progress in rehabilitation. Perceived exertion (option A) can be subjective and influenced by factors such as pain tolerance or emotional state, making it less reliable for quantifying endurance objectively. Heart rate response (option B) may vary based on individual fitness levels or medications, and may not always directly correlate with endurance capacity. Elapsed time (option C) is a measure of the duration of the test but does not provide specific information about the patient's endurance level in terms of physical capacity. In an educational context, understanding the rationale behind selecting the appropriate variable for a specific assessment helps healthcare professionals make informed decisions in patient care. By choosing the most relevant measure, therapists can accurately evaluate a patient's progress, tailor interventions effectively, and set appropriate goals for rehabilitation.

Correct Answer: B

Rationale: The correct answer to the question is B) Fluid accumulation in the lungs. In the case of left-sided heart failure, the heart is unable to effectively pump blood from the lungs to the rest of the body, leading to a backup of blood in the lungs. This congestion results in fluid leaking from the capillaries into the air sacs in the lungs, causing pulmonary edema. This fluid accumulation in the lungs is responsible for the patient's symptoms of persistent cough and shortness of breath. Option A) Decreased venous return to the heart is incorrect because in left-sided heart failure, blood returning to the heart from the body (venous return) is not the primary issue. The main problem lies in the heart's inability to pump effectively to the body. Option C) Increased systemic circulation is incorrect because left-sided heart failure typically leads to decreased systemic perfusion due to inadequate delivery of oxygenated blood to the tissues. Option D) Increased right ventricular preload is incorrect as it refers to the amount of blood in the right ventricle before contraction, which is not directly related to the symptoms described in the patient with left-sided heart failure. From an educational perspective, understanding the pathophysiology of heart failure and its impact on different organ systems is crucial for healthcare professionals to provide effective care and interventions for patients with heart failure. Recognizing the signs and symptoms of fluid overload in heart failure patients is essential for timely intervention and management to improve patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Lateral trunk bending. When a patient with a left transfemoral amputation is fitted with a prosthesis that is too short, it can lead to the individual leaning towards the side of the amputated limb in an attempt to make contact with the ground. This results in lateral trunk bending to compensate for the inadequate prosthesis length. Option A) Circumduction is a gait deviation where the leg swings out to the side in a circular motion, typically seen in cases of hip flexor weakness or spasticity, not due to a short prosthesis. Option C) Vaulting is when a person raises their body higher than necessary during the swing phase to clear the foot, often due to excessive length of the prosthesis, not a short prosthesis. Option D) Medial whip is a gait deviation where the residual limb swings medially during the swing phase, a result of a poorly aligned or excessively long prosthesis, not a short prosthesis. Understanding gait deviations is crucial in prosthetic fitting to ensure optimal function and comfort for the patient. Recognizing these deviations helps in adjusting the prosthesis appropriately, highlighting the importance of precise prosthetic fitting for individuals with limb loss.