Correct Answer: A

Rationale: The correct answer is to instruct the UAP to obtain emergency help first. When a client is unresponsive, it could indicate a life-threatening condition that requires immediate intervention. Ensuring emergency help is on the way is the priority to address the potentially critical situation. Feeling for a carotid pulse, bringing a glucometer, or checking the blood pressure are important assessments but should come after taking steps to secure immediate assistance.

Correct Answer: C

Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.

Correct Answer: C

Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice
A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice
B) can be seen in both localized and systemic infections. Chills and shivering (choice
D) are more related to the body's response to fever and not specifically indicative of a localized infection.

Correct Answer: B

Rationale: Acknowledging the client's feelings and providing emotional support without pressuring them to look at the incision is important.
Choice B is the best response as it respects the client's emotional readiness to confront their body image changes. The client's autonomy and emotional needs are prioritized in this response.
Choice A may invalidate the client's feelings by assuming the incision is not as bad as they think, potentially dismissing their emotions.
Choice C is insensitive as it imposes a particular view of recovery on the client, disregarding their current emotional state.
Choice D may escalate the situation by suggesting the need for another nurse, which could make the client feel uncomfortable and pressured.

Correct Answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice
A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice
C) and elevating legs on pillows (choice
D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.