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This is a modifiable risk factor, as individuals can improve their diet by choosing healthier foods, controlling portion sizes, and reducing intake of processed foods, thereby decreasing disease risk.

Smoking is modifiable because it can be stopped through behavioral interventions, medications, and support programs. Quitting significantly reduces the risk of cardiovascular and respiratory diseases.

Excessive sun exposure is also a modifiable risk factor. Protective measures like using sunscreen, wearing protective clothing, and avoiding peak sun hours can prevent skin damage and lower cancer risk.

This indicates decreased urine output (oliguria), which could suggest impaired renal perfusion or fluid imbalance. Although concerning, it does not take immediate priority over airway compromise.

This change is important to monitor but does not pose an immediate threat to airway, breathing, or circulation. The nurse can assess this client after stabilizing those with life-threatening conditions.

While the fever requires follow-up and may delay discharge, it is not an immediate life-threatening concern compared to airway compromise from wheezing.

This indicates the client recognizes a visual need, not a literacy issue. Using corrective lenses to read educational materials demonstrates awareness and willingness to learn, not a barrier to health literacy.

This response reflects experience-based confidence, not a literacy issue. The nurse should still verify understanding, but the client’s statement doesn’t directly suggest difficulty processing health information.

This indicates a positive learning attitude and motivation for self-care, showing the client is engaged and capable of understanding health-related instructions.

While the crash cart is essential for advanced resuscitation, starting chest compressions takes priority. The nurse should begin CPR immediately while another team member retrieves the cart.

Ventilation is important, but chest compressions should be initiated first to maintain circulation and perfusion. Once compressions are underway, airway and breathing support can follow according to the CAB (Circulation, Airway, Breathing) sequence of Basic Life Support (BLS).

Attaching the AED is a crucial step, but it should occur after or while chest compressions are in progress, as delays in compressions reduce the chances of survival.

This reflects advocacy, where the nurse protects and supports the client’s autonomy and right to make informed health decisions.

This is an example of client education, a key nursing role, but it focuses on teaching rather than personal accountability.

This demonstrates advocacy or collaboration, not accountability. It involves facilitating communication to ensure the client’s concerns are addressed, rather than taking responsibility for personal nursing actions.

The planning step involves developing goals, expected outcomes, and interventions based on the identified nursing diagnoses. It occurs after data collection, not during the initial interview.

The diagnosis step requires the nurse to analyze assessment data to identify actual or potential health problems. The nurse cannot make a diagnosis until all relevant information has been gathered.

Evaluation occurs after interventions are implemented and focuses on determining whether the client’s goals and outcomes have been met. It does not apply to an initial interview situation.

Assault refers to threatening or attempting to touch a person without consent, causing them to fear harm. In this case, the nurse did not merely threaten — they actually performed the act — so it is battery, not assault.

Negligence is an unintentional tort that occurs when a nurse fails to act as a reasonable and prudent nurse would, resulting in harm. Administering a medication without consent is intentional, not negligent.

False imprisonment involves restricting a person’s freedom of movement without legal justification (e.g., restraining a client without an order). The nurse did not confine the client but instead performed an unwanted procedure, making this battery, not false imprisonment.

A living will allows a client to specify preferences for life-sustaining treatments, such as mechanical ventilation or resuscitation, in the event they are unable to communicate their wishes.

As long as the client is competent, they can revoke or modify their advance directives or change their designated proxy at any time.

The proxy (or durable power of attorney for health care) only becomes active when the client loses decision-making capacity.

Evaluation occurs after interventions have been implemented and focuses on determining whether the goals and expected outcomes were achieved. It does not involve selecting interventions.

Implementation is the step where the nurse carries out or delegates the planned interventions, not where the interventions are identified or chosen.

During this step, the nurse interprets assessment data to identify the client’s actual or potential health problems and formulates nursing diagnoses. It does not include deciding on specific interventions yet.