Choice A rationale:

The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.

Choice B rationale:

The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.

Choice C rationale:

The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.

Choice D rationale:

The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.

Choice A rationale:

Tightening abdominal muscles is not the first action the nurse should take when repositioning a client. Repositioning a client requires proper body mechanics and coordination. Tightening abdominal muscles may not be as effective or safe as other actions in ensuring the client's safety during repositioning.

Choice B rationale:

Raising the height of the client's bed is not the first action the nurse should take when repositioning a client. Adjusting the bed height is a secondary consideration and can be done after ensuring proper body mechanics and patient safety during the repositioning process.

Choice C rationale:

Pivoting the feet in the direction of the move is a crucial step when repositioning a client. This action allows the nurse to maintain balance and control during the transfer. It also reduces the risk of injury to the nurse and the client. However, it is not the first action to be taken.

Choice D rationale:

Placing the feet in line with the shoulders is the first action the nurse should take when repositioning a client. This wide base of support provides stability and balance. It allows the nurse to maintain control during the repositioning process, reducing the risk of injury to both the nurse and the client. After achieving this stable stance, pivoting the feet in the direction of the move is the next step to facilitate the repositioning.

Choice A rationale:

Health education involves providing information and knowledge to clients to help them make informed decisions about their health. It focuses on teaching individuals about health-related topics. In this scenario, the nurse is not engaged in health education but rather in blood pressure screening, which is a form of health assessment and monitoring.

Choice B rationale:

Health promotion involves activities that encourage and empower individuals to take control of their health and well-being. It aims to enhance the overall health of the population. While blood pressure screening is a preventive measure, it does not encompass the broader concept of health promotion. It is more specific to early detection and monitoring of health conditions.

Choice C rationale:

Holistic health refers to an approach that considers the physical, emotional, social, and spiritual aspects of an individual's well-being. It recognizes the interconnectedness of these aspects and seeks to address them in a comprehensive manner. Performing a blood pressure screening, while important, is a specific health assessment task and does not fully encompass the holistic health approach.

Choice D rationale:

Disease prevention involves activities and measures taken to reduce the occurrence and impact of specific diseases. In this scenario, the nurse is performing a blood pressure screening for a client with a family history of hypertension. This screening is a preventive measure aimed at detecting and preventing the development of hypertension, which falls under the category of disease prevention. By identifying clients at risk, healthcare providers can intervene early and implement strategies to prevent or manage the condition. .

Choice A rationale:

Piaget's formal operational stage is characterized by abstract thinking, hypothesis testing, and logical reasoning, but it does not include the development of object permanence. This stage typically occurs during adolescence, not in early childhood when object permanence is established.

Choice B rationale:

The preoperational stage is characterized by the development of symbolic thought and egocentrism but not object permanence. Object permanence starts to develop during the sensorimotor stage.

Choice C rationale:

Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events. It does not include the development of object permanence, which occurs in the earlier sensorimotor stage.

Choice D rationale:

Object permanence is a concept that develops during Piaget's sensorimotor stage, which typically occurs from birth to about two years of age. During this stage, children learn that objects continue to exist even when they are out of sight. They develop the ability to represent objects mentally and understand the concept of permanence.

The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."

Choice A rationale:

• Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
• Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
• It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.

Choice B rationale:

• Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
• Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
• Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.

Choice C rationale:

• While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
• The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
• More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.

Choice D rationale:

• Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
• Other potential symptoms of diabetic retinopathy include:
  • Blurred vision
  • Floaters (dark specks or strings that move across the visual field)
  • Difficulty seeing at night or in low light
  • Loss of central vision
  • Distortion of colors
  • Blind spots

Choice A rationale:

Abstract thinking develops during Piaget's formal operational stage, not the preoperational stage. The preoperational stage is characterized by symbolic thinking and egocentrism but lacks the ability for abstract thought.

Choice B rationale:

Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events, and it does not involve abstract thinking. Abstract thinking, including hypothetical and deductive reasoning, is a feature of the formal operational stage.

Choice C rationale:

Abstract thinking and formal operational thought develop during Piaget's formal operational stage, which typically begins in adolescence and continues into adulthood. This stage is characterized by the ability to think logically, solve complex problems, and consider abstract concepts.

Choice D rationale:

The sensorimotor stage is the earliest stage in Piaget's theory of cognitive development, and it is primarily concerned with sensory and motor exploration. Abstract thinking is not a component of this stage. .

Choice A rationale:

Spirituality can increase feelings of hopelessness. This statement is not accurate. In many cases, spirituality can provide comfort, support, and a sense of hope for individuals who are nearing the end of life. Many people turn to their faith and spirituality as a source of strength and consolation during difficult times.

Choice B rationale:

Spirituality can increase the desire to hasten death. This statement is not generally true. Spirituality often has the opposite effect by providing a sense of purpose and meaning in life, which can help individuals find reasons to continue living. While some individuals may grapple with complex feelings related to death, it's not a typical outcome of embracing spirituality.

Choice C rationale:

Spirituality can increase depression. This statement is not accurate. Spirituality can actually serve as a source of emotional support and resilience for individuals facing the end of life. It can help individuals cope with their emotions and provide a sense of peace and comfort.

Choice D rationale:

Spirituality can increase the quality of life. This statement is correct. Spirituality often plays a positive role in the lives of individuals nearing the end of life. It can enhance the quality of life by providing emotional and psychological support, promoting a sense of purpose, and helping individuals find comfort and peace during this challenging time.

Choice A rationale:

Fibromyalgia. Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, and tender points. It is not an example of acute pain. Acute pain typically has a sudden onset and is of limited duration.

Choice B rationale:

Peripheral neuropathy. Peripheral neuropathy can cause both acute and chronic pain, depending on the underlying cause. However, it is not a classic example of acute pain. Acute pain is usually associated with a specific injury or condition and has a sudden onset.

Choice C rationale:

Rheumatoid arthritis. Rheumatoid arthritis is a chronic autoimmune condition that can cause joint pain and inflammation. While it can have acute flares of pain, it is primarily considered a chronic condition. Acute pain typically results from injuries or conditions with a sudden onset.

Choice D rationale:

Surgical incision. This is the correct answer. A surgical incision represents a classic example of acute pain. It is a pain that results from a specific event, in this case, surgery, and typically has a well-defined onset and duration. Acute pain is often sharp and intense, and it resolves as the incision heals.

Choice A rationale:

Clean the client's skin with hot water. Using hot water to clean a client's skin who is incontinent can be harmful. Hot water can damage the skin and exacerbate any existing skin issues. It is essential to use lukewarm water and gentle, pH-balanced cleansers to prevent skin irritation.

Choice B rationale:

Dry between folds in the client's skin. This is the correct answer. When caring for a client who is incontinent, it is crucial to ensure that the skin is kept clean and dry. Moisture between skin folds can lead to skin breakdown and the development of pressure ulcers. Drying the skin thoroughly helps prevent these issues.

Choice C rationale:

Apply baby powder to the client's skin. Applying baby powder is not recommended, as it can create a moist environment that may promote the growth of fungi and bacteria. It can also potentially lead to respiratory issues if the client inhales the powder. It's better to focus on keeping the skin clean and dry without using powder.

Choice D rationale:

Restrict the client's fluid intake. Restricting the client's fluid intake is not a suitable approach. Adequate hydration is essential for overall health and well-being. Dehydration can lead to various complications and negatively impact the client's overall health. Instead, focus on managing incontinence through appropriate hygiene and the use of incontinence products. .

Choice A rationale:

The "Region" in the PQRST mnemonic refers to the location of the pain. It helps identify where the pain is occurring in the body. While this information is important, it does not address the quality or nature of the pain, which is what the nurse is asking the client to describe.

Choice B rationale:

"Severity" in the PQRST mnemonic relates to how intense the pain is. It helps in assessing the degree of pain the client is experiencing, but it does not address the quality or nature of the pain, which is what the nurse is inquiring about.

Choice C rationale:

"Quality" in the PQRST mnemonic pertains to the description of the pain itself. It helps the nurse understand the characteristics of the pain, such as whether it is sharp, dull, burning, throbbing, etc. This information is essential for a more accurate assessment of the pain's underlying cause, making it the correct choice in this scenario.

Choice D rationale:

"Precipitating cause" in the PQRST mnemonic is concerned with what factors or actions might trigger the pain. While this information is valuable, it does not directly address the nature or quality of the pain, which is what the nurse is trying to assess.