61. Key: A

Client Need: Management of Care

A. All facts should be documented exactly as the patient stated. When recording subjective data, document the client's exact words within quotation marks.

B. The use of such words as appears, seems or apparently is not acceptable when documenting because they suggest that the nurse did not know the facts.

C. The patient's comment is subjective data and should be placed in the patient's own words.

D. The patient's comment is subjective data and should be placed in the patient's own words.

62. Key: D                                                

Client Need: Reduction of Risk Potential

D. The radiated skin should be protected from sunlight and extreme cold. The nurse should instruct the patient to keep the skin dry; not apply lotions, powders. creams, alcohol or deodorants; wear loose-fitting garments; not apply tape. shave with an electric razor; and protect the skin from direct sun-light. chlorinated pools and temperature extremes.

A. The dark ink markings that outline the radiation field should be left intact. They should not be washed off.

B. Applying any lotions, perfumes, deodorants or powder to the treatment area is contraindicated.

C. Non-restrictive cotton clothing should be worn over the treatment area.

63. Key: D                                              

Client Need: Safety and Infection Control

D. Restraints should be secured to the bed frame. Hospital bed frames are typically sturdy and immovable and therefore can be safely used in a restraint situation.

A. Side rails can be easily moved. Restraints anchored to side rails present a danger to both patients and staff.

B. Restraints may become loosened from mattress hooks and present a hazardous situation.

C. The footboard of the bed may not be secure enough for restraints, presenting a hazard.

64. Key: B                                                   

Client Need: Psyckosocial Adaptation

B. The nursing diagnosis of spiritual distress is appropriate for the suicidal client who is experiencing a lack of hope for the future and a feeling of despair.

A. Ineffective coping may describe the individual's lack of problem-solving skills that led to the suicidal ideation or intent, but is not related to feelings of despair.

C. Anxiety may be appropriate to describe the suicidal client's concerns regarding the future. It may also be a response to a situational crisis. However, it does not best describe the feelings of despair.

D. Dysfunctional grieving resulting from a loss may contribute to the person feeling isolated and confused and lead to the suicidal feelings. However, spiritual distress better describes the individual's feeling of despair.

65. Key: B                                                  

Client Need a Growth and Development

B. Normal physiological changes of aging include a decreased rate of voluntary or autonomic reflexes.which increases the risk of injury.

A. Normal physiological changes of aging include decreased muscle mass and strength.

C. Normal physiological changes of aging include decreased cognitive ability.

D. A thin white ring along the margin of the iris is called arcus senilis. This is common with aging but does not increase the risk of injury.