Choice A rationale: Referring the client to a dietitian for nutrition education is a proactive step. Dietitians can provide personalized guidance and address the client's dietary concerns and preferences. However, this alone may not be sufficient if the client is strongly resistant to dietary changes.

Choice B rationale: Providing pamphlets about heart-healthy diet selections is informative but may not effectively address the client's resistance to dietary changes. The client's reluctance needs to be explored and addressed through a more interactive approach.

Choice C rationale: While exercise is important for heart health, the primary concern here is the client's elevated cholesterol levels, which are significantly impacted by dietary choices. Suggesting exercise alone may not adequately address the issue at hand.

Choice D rationale: Discussing the client's concerns about the change in diet is the most appropriate initial action. It allows the nurse to understand the client's perspective, identify barriers to compliance, and work collaboratively with the client to develop a plan that considers his preferences and challenges. This approach is more likely to lead to a successful change in diet and lifestyle compared to simply providing information or referrals.

Choice A: Flavored gelatin can be a choice if the client enjoys it, but it should not be the primary source of nutrition as it lacks protein and other essential nutrients needed for healing.
Choice B: Eggs are a good source of protein, which is essential for tissue repair and healing.
Choice C: Soda crackers are low in protein and do not provide adequate nutrition for postoperative healing.
Choice D: Baked chicken is a lean source of protein and can be a part of a balanced postoperative diet.
Choice E: Salmon is rich in omega-3 fatty acids and protein, which can support the healing process and provide essential nutrients.

Choice A: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.

Choice B: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.

Choice C: Skim milk, grapes, and lettuce are good sources of water that can help dilute the sodium level in the blood. Bacon is a high-sodium food, but it is a small portion compared to the other choices and can be balanced by the rest of the meal.

Choice D: this combination contains higher sodium levels, especially canned soup, so it's not the ideal choice.

Choice A: Uremic frost is a symptom of advanced kidney disease and can result in deposits of urea crystals on the skin. This can cause itching and discomfort, making it difficult for the client to maintain good hygiene and self-care. Therefore, addressing hygiene self-care deficit related to uremic frost is a priority in the plan of care for a client with renal osteodystrophy.

Choice B: This is not directly related to renal osteodystrophy and is more related to the presence of a catheter.

Choice C: This is not typically associated with renal osteodystrophy unless there are specific mobility issues related to bone problems.

Choice D: This may be relevant for clients with CKD, but it is not specific to renal osteodystrophy, which primarily involves bone mineral imbalances.

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.

Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.

Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.

Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.

Choice A: This response indicates an understanding of the need to avoid high- risk activities that could worsen the condition or cause injury to the affected leg, which is appropriate after acute osteomyelitis.

Choice B: While exercise is important, it should be done under medical guidance, especially after a significant illness like acute osteomyelitis.

Choice C: Resuming normal activities may not be appropriate immediately, and the level of activity should be determined by the healthcare provider.

Choice D: Keeping the leg immobile is not typically recommended as it can lead to muscle atrophy and other complications.

Choice A: A high protein diet is generally not recommended for clients with glomerulonephritis, as it can put additional strain on the kidneys.

Choice B: In glomerulonephritis, there is impaired kidney function, and sodium and fluid restrictions are often necessary to manage fluid balance and blood pressure.

Therefore, the nurse should instruct the client to restrict sodium-rich foods and excessive oral fluids.

Choice C: A low carbohydrate diet with low glycemic index foods is not a specific dietary recommendation for managing glomerulonephritis.

Choice D: Dietary potassium restriction may vary depending on the individual client's potassium levels and needs, so it should be determined by the healthcare provider. It is not a blanket recommendation for all clients with glomerulonephritis.

Choice A: Permethrin cream may cause temporary itching and skin irritation as it works to eliminate the scabies mites. Instructing the client to remove the cream immediately if pruritis occurs is not necessary; it is a common and expected side effect during treatment.

Choice B: Reapplication of permethrin is not typically done in seven days unless directed by the healthcare provider. A single application is often effective in treating scabies.

Choice C: Showering or bathing 8 to 14 hours after permethrin treatment is a common instruction to remove the cream and dead mites. This is an important part of the treatment process.

Choice D: Avoiding areas between fingers and toes during application is not necessary, as permethrin is generally safe for use on these areas. However, it should not be applied to the face or near the eyes.

Choice A: Documenting the findings in the record is appropriate, but it should not be the only action taken when there is an unusual discoloration on an infant's skin.

Choice B: Reporting possible child abuse to protective services should be done if there are strong suspicions or evidence of abuse. However, a bluish-black discoloration alone may not necessarily indicate abuse, so further assessment and information gathering are needed.

Choice C: Gently rubbing the area with skin cream is not appropriate without a clear understanding of the cause of the discoloration. It's important to first assess and gather information.

Choice D: Asking the mother about the discoloration is the most appropriate initial action. It's important to gather information about the infant's history, potential birthmarks, or other factors that could contribute to the discoloration.

Choice A rationale: A room that contains very little furniture may not be suitable for a client in an elated state, as it may lack the structure and safety precautions needed for someone experiencing manic or related symptoms.

Choice B rationale: A room that has at least two other clients assigned to it may not be the best choice, as the presence of other clients could potentially escalate the client's symptoms or create interpersonal conflicts.

Choice C rationale: Placing the client in a quiet room away from the nurse's station is a reasonable consideration. However, it may not provide the necessary level of supervision and immediate intervention if the client's symptoms become more severe.

Choice D rationale: A bright-colored room located near the recreation room is a suitable choice. It allows for a visually stimulating environment and easy access to activities and social interactions while providing a level of supervision and support from the staff.

Choice A: Teaching clients about the potential side effects of antipsychotic drugs is important, but it is not the most critical aspect of medication administration policy. Monitoring for side effects and adverse reactions is typically the responsibility of healthcare providers and nursing staff.

Choice B: Monitoring all clients receiving antipsychotic drugs for indications of tardive dyskinesia is a crucial standard to include in the policy. Tardive dyskinesia is a serious side effect associated with long-term use of antipsychotic medications, and early detection and intervention are essential to prevent its progression.

Choice C: Ensuring that all clients treated with antipsychotic drugs receive prompt renewals as needed is important for continuity of care, but it is not the primary focus of a policy for administering antipsychotic medications.

Choice D: Documenting all client therapeutic serum levels related to antipsychotic medications is relevant but may not apply to all clients receiving these medications. Monitoring for side effects and adverse reactions is generally more universally applicable and critical to patient safety.

Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.

Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.

Adjusting the rate this way would require an infusion pump.

Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.

Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.

Choice A: A thready pulse is one that is weak and can be easily obliterated by light pressure.

Choice B: A missing pulse is one that cannot be felt at all.

Choice C: "Pulse skips beats" is a different phenomenon and not an accurate description of the pulse disappearing with light pressure. It is irregular and may indicate a cardiac arrhythmia.

Choice D: Documenting "light pressure applied to pulse" does not convey the specific finding that the pulse disappears with pressure, which is more clinically relevant. It is not a finding, but a method of assessing the pulse.

Choice A: Comprehension of simple commands is an earlier developmental stage and not directly related to the infant's ability to search for a fallen toy.

Choice B: Exploration beyond caregiver presence is a key characteristic of the sensorimotor stage in Piaget's theory. During this stage, infants develop object permanence and begin to explore their environment independently.

Choice C: Visible or audible separation anxiety is common during the early stages of infancy and is not specific to the sensorimotor stage.

Choice D: The ability to place objects in a container is more related to later developmental stages when fine motor skills are more developed.

Choice A: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice B: Chilling the enema solution is not recommended because it can cause cramping, discomfort, and vasoconstriction, which may interfere with the client's fever assessment.

Choice C: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice D: Inserting the lubricated tip of tubing 3 to 4 inches into the rectum prevents injury to the rectal mucosa and ensures proper placement of the tubing.

Choice E: Clamping the enema administration tubing after filling the enema bag is unnecessary and may cause air to enter the tubing, which can increase the risk of abdominal distension and gas pain.

Choice A: Impaired cognition is not a common manifestation of Cushing's syndrome. Cushing's syndrome is primarily characterized by hormonal imbalances and physical symptoms.

Choice B: Memory loss is not a common manifestation of Cushing's syndrome. The syndrome is more associated with hormonal and metabolic disturbances.

Choice C: Mood alterations, including irritability, anger, and emotional instability, are common manifestations of Cushing's syndrome. These mood changes can be attributed to the hormonal imbalances and physiological stress associated with the condition.

Choice D: Hearing loss is not a recognized symptom of Cushing's syndrome. Mood alterations and physical changes are more typical.

Choice A: Checking mental acuity is important for assessing the client's cognitive function, but it may not be the most crucial intervention in the context of left- sided heart failure.

Choice B: Measuring urinary output is a valuable assessment in clients with heart failure, but it is not the most important intervention among the choices provided.

Choice C: Inspecting for sacral edema is a relevant assessment for clients with heart failure, especially when assessing for fluid retention. However, it may not be the highest priority in this case.

Choice D: Auscultating all lung fields is the most important intervention for a client with left-sided heart failure. Left-sided heart failure often results in pulmonary congestion, and auscultating the lung fields can provide critical information about the presence of crackles, wheezes, or other abnormal breath sounds, indicating worsening heart failure.

Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.

Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.

Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.

Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.

Choice A: A platelet count of 135,000/mm3 is slightly below the lower end of the normal range, but it may not be considered critically low. It is not the highest priority finding among the choices provided.

Choice B: A blood urea nitrogen (BUN) level of 75 mg/dL is significantly elevated and outside the normal range. Elevated BUN can indicate kidney dysfunction or dehydration and should be reported promptly.

Choice C: Decreased deep tendon reflexes may be related to various factors, including medication effects, and may not be considered the highest priority finding unless it is associated with other concerning symptoms.

Choice D: Periodic nausea and vomiting can be common side effects of chemotherapy, but they may not be considered the highest priority finding unless they are severe, persistent, or associated with signs of dehydration or electrolyte imbalances.

Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.

Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.

Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.

Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.

Choice A: Urine appearing very dilute may be a concern but is not the most critical finding in a client with diabetic ketoacidosis (DKA).

Choice B: The client not being responsive is the most important finding to report. It may indicate a worsening of the client's condition, possibly related to the progression of DKA or other complications.

Choice C: A fruity odor to the breath is a common symptom of DKA and may have been present upon admission. While it is important to monitor, it is not the highest priority among the choices provided.

Choice D: Flushed and dry skin can be a symptom of DKA but is not the most important finding to report if the client is unresponsive. The client's level of consciousness takes precedence.

Choice A: A complete blood count (CBC) is important for monitoring various aspects of the blood, including the number of red blood cells, white blood cells, and platelets. While important for assessing overall health, a CBC is not the primary laboratory finding used to assess the effectiveness of warfarin in managing atrial fibrillation.

Choice B: Serum troponin levels are typically measured to assess cardiac muscle damage, such as in myocardial infarction (heart attack). They are not the primary indicator for assessing the effectiveness of warfarin in atrial fibrillation.

Choice C: Creatinine clearance is a measure of kidney function and is not the primary laboratory finding used to evaluate the effectiveness of warfarin.

Choice D: Prothrombin time (PT) is the most relevant laboratory finding for monitoring the effectiveness of warfarin in clients with atrial fibrillation. Warfarin's therapeutic effect is primarily assessed through PT measurements, with the goal of maintaining the client's international normalized ratio (INR) within a specific target range to prevent excessive bleeding or clotting.

Choice A: Sitting quietly in her mother's lap may be a sign of shyness or caution in a healthcare setting, but it is not necessarily a typical behavior for a 4-year-old child.

Choice B: Drawing a picture of oneself with facial features is a more advanced skill and may be seen in older preschool-aged children. It is not a typical behavior for a 4- year-old.

Choice C: Talking to an imaginary friend is a normal and developmentally appropriate behavior for a 4-year-old child. Imaginary friends can provide comfort and companionship during times of stress or change.

Choice D: Ignoring other children in the play area may be a sign of shyness or introverted behavior but is not necessarily indicative of normal behavior for a 4-year-old. Social interaction with peers can vary widely among children.

Choice A: Closing the blinds to darken the room may not be the immediate priority during a seizure. Ensuring the safety and well-being of the child takes precedence.

Choice B: Asking the mother to release the child is an important action. It is essential to prevent any further physical restraint during a seizure, as it can cause harm to the child or the person attempting to restrain them.

Choice C: Monitoring the child's airway and tongue is crucial during a seizure to prevent any obstruction that could interfere with breathing. It is important to ensure the child does not choke on saliva or vomit.

Choice D: Administering an anticonvulsant medication may be necessary in certain situations, especially if the seizure persists or is prolonged. The healthcare provider's orders should be followed for the administration of appropriate medications

Choice E: Placing pillows inside the side rails is not a relevant intervention during a seizure. The focus should be on ensuring the child's safety, assessing their airway, and providing appropriate care during the seizure.