Correct Answer: D

Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).

Correct Answer: A

Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.

Correct Answer: C

Rationale: Although the client will need factual information about the postoperative period and recuperation, the nurse should place priority on addressing loss of reproductive ability as a psychological concern. The radical effects of this surgery in the reproductive area make it likely that the client may have some difficulty in adjustment to this consequence of surgery.

Correct Answer: C

Rationale: Impaired tissue perfusion is an intrinsic risk factor for pressure ulcers, as it reduces oxygen and nutrient delivery to tissues, increasing susceptibility to breakdown.

Correct Answer: A

Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.