Choice A reason: Reminiscence therapy is a type of intervention that helps clients with Alzheimer's disease recall and share their past experiences, memories, and emotions. This can enhance their self-esteem, mood, and quality of life. By requesting a referral for this therapy, the nurse is advocating for the client's psychosocial needs and preferences.

Choice B reason: Performing an updated cognitive assessment on the client is not an example of advocacy, but rather a standard nursing practice. Cognitive assessments are used to monitor the client's cognitive status and progression of the disease. They do not necessarily reflect the client's wishes or interests.

Choice C reason: Providing assistance for the client when ambulating down the hall is not an example of advocacy, but rather a safety measure. The nurse is helping the client prevent falls and injuries, which are common risks for clients with Alzheimer's disease. This does not imply that the nurse is speaking up for the client or protecting their rights.

Choice D reason: Reorienting the client several times throughout the day is not an example of advocacy, but rather a therapeutic communication technique. The nurse is helping the client cope with confusion and disorientation, which are common symptoms of Alzheimer's disease. This does not indicate that the nurse is supporting the client's goals or values.

Choice A reason: The client's vital signs are not part of the background information, but rather the assessment information. The background information should include relevant and concise data about the client's history, diagnosis, and treatment.

Choice B reason:The client's name is part of the Situation component, which is the "S" in SBAR. This first step establishes the identity of the patient and the reason for the communication. Background, conversely, focuses on the clinical history and factors that led up to the current situation, rather than basic identifiers used to open the conversation.

Choice C reason:Background information includes the clinical context and history pertinent to the client's care, such as medical history, allergies, and code status. Knowing the code status provides the receiving nurse with essential historical legal and clinical context regarding the client’s wishes and limitations of care, which is a foundational element of the "B" in SBAR.

Choice D reason: A prescribed consultation is not part of the background information, but rather the situation information. The situation information should describe the current problem or reason for the transfer.

Choice A reason: Providing coverage for the nurses' breaks is a possible action that the charge nurse can take, but it is not the first one. The charge nurse should first assess the situation and identify the factors that are preventing the nurses from taking their breaks.

Choice B reason: Reviewing facility policies for taking scheduled breaks is an important action that the charge nurse can take, but it is not the first one. The charge nurse should first communicate with the nurses and understand their perspectives and needs.

Choice C reason: Determining the reasons the nurses are not taking scheduled breaks is the first action that the charge nurse should take. This will help the charge nurse to address the root cause of the problem and provide appropriate support and guidance to the nurses.

Choice D reason: Discussing time management strategies with the nurses is a helpful action that the charge nurse can take, but it is not the first one. The charge nurse should first determine if the nurses are facing any barriers or challenges that are affecting their ability to take their breaks.

Choice A reason: A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is at risk of tissue ischemia and necrosis, which are serious complications. However, this is not the highest priority, as the condition is chronic and not acute.

Choice B reason: A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is facing a life-threatening illness and needs emotional and physical support. However, this is not the highest priority, as the client is stable and not experiencing any immediate complications.

Choice C reason: A client who has MRSA and has an axillary temperature of 38°C (101°F) has an infection that can spread to other clients and staff, and needs isolation and antibiotic therapy. However, this is not the highest priority, as the fever is mild and the infection is treatable.

Choice D reason: A client who is postoperative following a laminectomy 12 hr ago and is unable to void has urinary retention, which can lead to bladder distension, pain, infection, and renal damage. This is the highest priority, as the client needs immediate intervention to relieve the obstruction and prevent further complications.

Choice A reason: A multigravida client with preeclampsia receiving misoprostol for induction of labor requires specialized obstetrical care due to the complexity of preeclampsia management, which includes monitoring blood pressure, administering antihypertensive agents, and managing potential complications. Misoprostol is used for cervical ripening and labor induction, which involves close monitoring for uterine activity and fetal well-being.

Choice B reason: A client with gestational diabetes undergoing biweekly nonstress tests would benefit from a nurse with obstetrical expertise. Gestational diabetes management includes monitoring blood glucose levels, dietary modifications, and possibly medication administration. Nonstress tests are performed to assess fetal well-being and require interpretation of fetal heart rate patterns in response to fetal movements.

Choice C reason: A client at 32 weeks of gestation with premature rupture of membranes (PROM) needs specialized obstetrical care. Management of PROM may involve expectant management or immediate delivery based on gestational age and fetal and maternal conditions. The risk of infection and complications necessitates obstetrical expertise.

Choice D reason: A primigravida client who is 1 day postoperative following a Cesarean section with a PCA pump is the most suitable assignment for an RN from a medical-surgical unit. Postoperative care involves monitoring vital signs, incision site, and managing pain with the PCA pump, which is within the scope of medical-surgical nursing practice.

Choice A reason: Administering a bronchodilator two times a day for a child who has cystic fibrosis is an appropriate intervention, as it helps to improve the child's respiratory function and prevent mucus accumulation.

Choice B reason: Checking the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago is an appropriate intervention, as it helps to monitor the child's circulation and nerve function and detect any signs of compartment syndrome.

Choice C reason: Maintaining eye shields for a newborn receiving phototherapy for hyperbilirubinemia is an appropriate intervention, as it helps to protect the newborn's eyes from the harmful effects of the light and prevent eye damage.

Choice D reason: Teaching an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet is an incorrect intervention, as it contradicts the dietary recommendations for this condition. A high-protein, low-fiber diet can worsen the inflammation and symptoms of ulcerative colitis. The nurse should teach the adolescent about a low-residue, high-calorie, high-protein diet instead.

Choice A reason: Using a pain rating scale to monitor a client's pain level is a task that the nurse can delegate to an assistive personnel, as it does not require clinical judgment or specialized skills. The assistive personnel can report the pain score to the nurse, who can then adjust the pain management plan accordingly.

Choice B reason: Instructing a client on self-administration of a tap water enema is a task that the nurse cannot delegate to an assistive personnel, as it requires teaching and evaluation skills. The nurse should instruct the client on the procedure, the rationale, and the expected outcomes, and assess the client's understanding and ability to perform the task.

Choice C reason: Performing a dressing change on a client's peripherally inserted central catheter is a task that the nurse cannot delegate to an assistive personnel, as it requires sterile technique and infection control skills. The nurse should perform the dressing change according to the facility protocol, and monitor the site for any signs of complications.

Choice D reason: Suctioning a client's long-term tracheostomy is a task that the nurse cannot delegate to an assistive personnel, as it requires advanced airway management skills. The nurse should suction the client's tracheostomy as needed, and observe the client for any signs of respiratory distress.

Choice A reason: Diminished hand-to-mouth coordination is a finding that indicates a motor deficit, not a speech or language problem. The nurse should refer the client to a physical therapist or an occupational therapist for this issue.

Choice B reason: Altered level of consciousness is a finding that indicates a cognitive impairment, not a speech or language problem. The nurse should monitor the client's mental status and report any changes to the provider.

Choice C reason: Unilateral ptosis is a finding that indicates a cranial nerve deficit, not a speech or language problem. The nurse should assess the client's eye movements and facial symmetry and report any abnormalities to the provider.

Choice D reason: Impaired voluntary cough is a finding that indicates a swallowing disorder, which is a speech or language problem. The nurse should refer the client to a speech-language pathologist for further evaluation and intervention. The client may have dysphagia, which can increase the risk of aspiration and pneumonia.

The correct answer is c.

Choice A reason: Providing the UAP with the infection control policy is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.

Choice B reason: Offering to assist the UAP with the collection of the specimen is not the first action the charge nurse should take. The charge nurse should first address the UAP's fear and educate the UAP about HIV transmission and infection control measures.

Choice C reason: Determining the UAP's knowledge about HIV transmission is the first action the charge nurse should take. This will help the charge nurse identify any knowledge gaps or misconceptions the UAP may have and provide appropriate education and reassurance.

Choice D reason: Demonstrating the proper use of personal protective equipment is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.

Choice A reason: Report of photophobia is a common finding in clients who have meningitis, as the inflammation of the meninges causes sensitivity to light. However, this is not an urgent finding that requires immediate reporting to the provider.

Choice B reason: Increased temperature is a common finding in clients who have meningitis, as the infection causes fever and systemic inflammation. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is very high or accompanied by other signs of sepsis.

Choice C reason: Decreased level of consciousness is an urgent finding in clients who have meningitis, as it indicates increased intracranial pressure, cerebral edema, or brain herniation. These are life-threatening complications that require immediate intervention and treatment.

Choice D reason: Generalized rash over trunk is a common finding in clients who have meningococcal meningitis, as the bacteria cause petechiae and purpura on the skin. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is extensive or associated with bleeding or shock.