Choice A reason: Urinary retention, the inability to void, is caused by bladder or prostate issues, not dietary fiber intake. Fiber affects gastrointestinal motility, not urinary function. High-fiber diets promote bowel regularity but have no direct impact on bladder emptying, making this choice incorrect.

Choice B reason: High-fiber diets prevent constipation by adding bulk to stool and promoting peristalsis, facilitating regular bowel movements. Fiber absorbs water, softening stool and reducing straining, which is critical for patients with poor nutrition, like Mr. Green, making this the correct choice for dietary intervention.

Choice C reason: Stress incontinence, urine leakage during physical stress, results from weakened pelvic muscles or sphincter dysfunction, not dietary factors. Fiber influences bowel health, not bladder control, so this choice is unrelated to the preventive benefits of a high-fiber diet in gastrointestinal function.

Choice D reason: Hiatal hernia, where the stomach protrudes through the diaphragm, is linked to anatomical or pressure factors, not fiber intake. Fiber supports bowel regularity but does not address esophageal or diaphragmatic issues, making this choice irrelevant to the benefits of high-fiber diets.

Choice A reason: A blood pressure of 90/80 mmHg is below normal, indicating hypotension, especially with a low systolic value. Normal adult blood pressure, per guidelines, is around 120/80 mmHg. Low readings may suggest dehydration or cardiovascular issues, requiring evaluation, making this choice incorrect.

Choice B reason: A reading of 95/60 mmHg is hypotensive, with both systolic and diastolic values below normal ranges. Normal blood pressure is approximately 120/80 mmHg, per American Heart Association guidelines. Such low readings may indicate shock or autonomic dysfunction, rendering this choice incorrect.

Choice C reason: A blood pressure of 180/60 mmHg is abnormal, with elevated systolic pressure indicating hypertension and a low diastolic value suggesting possible aortic regurgitation. Normal blood pressure is 120/80 mmHg. This reading requires urgent assessment, making it an incorrect choice for normal adult values.

Choice D reason: A blood pressure of 120/80 mmHg is considered normal for adults, per current guidelines like those from the American Heart Association. It reflects balanced systolic and diastolic pressures, indicating healthy cardiovascular function without signs of hypertension or hypotension, making it the correct choice.

Choice A reason: A blood pressure of 90/60 mmHg is hypotensive, indicating potentially inadequate perfusion to organs, which may result from dehydration, shock, or medication effects. This reading is concerning and requires reporting to the doctor for further evaluation and management to prevent complications like organ failure.

Choice B reason: A blood pressure of 125/68 mmHg is within normal to slightly elevated ranges, not immediately concerning. It does not warrant urgent reporting unless accompanied by symptoms or trends suggesting instability, as it aligns with typical adult values under most clinical guidelines.

Choice C reason: A blood pressure of 144/76 mmHg is elevated but not critical unless persistent or symptomatic. It suggests prehypertension or early hypertension, which may need monitoring but not immediate reporting unless other clinical factors, like symptoms or patient history, indicate urgency.

Choice D reason: A blood pressure of 150/70 mmHg is elevated, indicating possible hypertension, but not an emergency unless accompanied by symptoms like chest pain. It requires monitoring rather than immediate reporting, as it falls short of hypertensive crisis thresholds like 180/120 mmHg.

Choice A reason: Pain rating is considered a subjective vital sign, assessed via patient self-reporting, often on a 0-10 scale. It reflects neurological and emotional status, guiding pain management. Including it as a vital sign is a valid clinical practice, making this choice a correct use.

Choice B reason: In less stable clients, vital signs should be checked more frequently than once daily, often every few hours, to monitor deteriorating conditions like sepsis or shock. This statement inaccurately suggests infrequent monitoring, which is not a standard use of vital signs, making it the correct answer.

Choice C reason: Vital signs assess circulatory (blood pressure, pulse), respiratory (respirations, pulse oximetry), neurological (via pulse and responsiveness), and endocrine (temperature) systems. They provide critical data on physiological function, making this a valid use of vital signs in comprehensive health assessments.

Choice D reason: Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximetry, which measure thermoregulation, cardiovascular, and respiratory status. This is a standard definition in clinical practice, accurately reflecting the components of vital sign assessment, making it a correct use.

Choice A reason: Rebound tenderness in the right lower quadrant, often at McBurney’s point, is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This sign, elicited by releasing pressure during palpation, suggests localized inflammation, requiring urgent surgical evaluation to prevent rupture and peritonitis.

Choice B reason: Pancreatitis typically presents with epigastric or left upper quadrant pain, radiating to the back, not right lower quadrant rebound tenderness. It involves pancreatic inflammation, often due to gallstones or alcohol, and is assessed via serum amylase and lipase, not RLQ findings, making this incorrect.

Choice C reason: Cholecystitis causes right upper quadrant pain and tenderness, often with Murphy’s sign, due to gallbladder inflammation. Rebound tenderness in the right lower quadrant is not characteristic, as cholecystitis affects the upper abdomen, making this choice misaligned with the clinical finding.

Choice D reason: Diverticulitis typically causes left lower quadrant pain, as diverticula are common in the sigmoid colon. Right lower quadrant rebound tenderness is not a typical finding, as it suggests appendicitis instead, making this choice incorrect for the described gastrointestinal assessment finding.

Choice A reason: The gastrointestinal tract does not provide oxygen to organs; this is the respiratory and circulatory systems’ role, delivering oxygen via lungs and blood. The GI tract focuses on digestion, absorption, and waste elimination, making this function unrelated to its physiological responsibilities.

Choice B reason: Elimination of waste is a core gastrointestinal function, achieved through defecation. The large intestine compacts waste into feces, expelling it via the rectum, a critical process for removing indigestible material and toxins, making this a valid GI tract function.

Choice C reason: Digestion of food is a primary gastrointestinal function, involving mechanical and chemical breakdown in the stomach and small intestine. Enzymes and acids process nutrients for absorption, a fundamental GI role, making this choice a correct description of its physiological tasks.

Choice D reason: Removing water-soluble waste is a gastrointestinal function, as the colon reabsorbs water, concentrating waste for elimination. This process ensures efficient waste management, distinguishing it from renal functions, making this a valid role of the GI tract in waste handling.

Choice A reason: Gender, while influencing health outcomes, is not a social determinant of health, which includes modifiable environmental and societal factors like income or housing. Gender is a biological and social characteristic, not an external condition shaping health access or outcomes, making it the correct answer.

Choice B reason: Physical environment, including housing, air quality, and access to green spaces, is a social determinant of health. It directly impacts health outcomes by influencing exposure to pollutants or access to safe living conditions, making it a valid factor in health disparities.

Choice C reason: Economic stability, encompassing income, employment, and financial security, is a social determinant of health. It affects access to healthcare, nutrition, and stress levels, significantly influencing health outcomes, making it a critical factor in public health frameworks.

Choice D reason: Access to health care, including availability of services and insurance, is a social determinant of health. It determines timely medical interventions and preventive care, directly affecting health outcomes, making it a key component in health equity discussions.

Choice A reason: The left lower quadrant contains the sigmoid colon and parts of the small intestine, not the liver. Liver assessment involves palpation and percussion in the right upper quadrant, where it resides, making this choice incorrect for locating the liver anatomically.

Choice B reason: The liver is located in the right upper quadrant, beneath the diaphragm, extending slightly into the left upper quadrant. It is assessed via percussion and palpation in the RUQ to evaluate size or tenderness, making this the correct choice for liver localization.

Choice C reason: The left upper quadrant houses the stomach, spleen, and parts of the pancreas, not the liver’s primary location. While the liver’s left lobe extends slightly into the LUQ, its main mass is in the RUQ, making this choice incorrect.

Choice D reason: The right lower quadrant contains the appendix and cecum, not the liver. Liver assessment targets the right upper quadrant, where its bulk resides, making this choice incorrect for identifying the liver’s anatomical position during physical examination.

Choice A reason: Limited ability to reposition is a major risk factor for pressure injuries, as immobility increases pressure on bony prominences, reducing blood flow and causing tissue ischemia. This leads to skin breakdown, particularly in bedridden patients, making it a critical factor in pressure ulcer development.

Choice B reason: Requiring stand-by assistance for activities of daily living (ADLs) indicates some mobility, as the patient can perform tasks with supervision. This does not inherently increase pressure injury risk, unlike immobility or moisture, making it the least relevant risk factor among the choices.

Choice C reason: Poor nutritional state is a risk factor for pressure injuries, as malnutrition impairs skin integrity and wound healing. Deficiencies in protein or vitamins reduce tissue resilience, increasing susceptibility to pressure-induced damage, particularly in elderly or debilitated patients.

Choice D reason: Moisture from incontinence, wound drainage, or perspiration softens skin, increasing friction and shear forces, which heighten pressure injury risk. It compromises skin barrier function, promoting maceration and ulceration, making it a significant contributor to pressure ulcer formation.

Choice A reason: Clear bilateral lung sounds are a normal respiratory finding, indicating unobstructed airways and effective gas exchange. Abnormal sounds like wheezing or crackles would suggest pathology, but this choice reflects expected lung function, not an unexpected assessment outcome.

Choice B reason: Absence of cough is a normal finding, suggesting no airway irritation or obstruction. Coughing may indicate infection or fluid accumulation, but its absence aligns with healthy respiratory status, making this a typical and expected assessment result.

Choice C reason: Using an incentive spirometer post-surgery is an expected finding, as it promotes lung expansion and prevents atelectasis. It indicates patient compliance with respiratory therapy, a standard post-operative intervention, not an abnormal or unexpected respiratory assessment outcome.

Choice D reason: An oxygen saturation of 90% on 2 liters of oxygen via nasal cannula is unexpected, as normal saturation should be 95-100%. This suggests hypoxemia, potentially from lung pathology or inadequate oxygen delivery, warranting further investigation, making it the correct choice.