Correct Answer: D

Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being.

Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.

Correct Answer: C

Rationale: The correct answer is C: Being in crowds during the periods of immunosuppression. Clients with autoimmune disorders have compromised immune systems, making them more susceptible to infections. Being in crowds increases the risk of exposure to various pathogens, potentially leading to infections. Avoiding crowds during periods of immunosuppression helps minimize the risk of infections.

A: Resting during the periods of severe exacerbation is important for managing symptoms and conserving energy, but it is not specifically related to avoiding triggers for autoimmune disorders.
B: Regular exercise during the periods of remission is beneficial for overall health and can help manage autoimmune disorders, as long as it is appropriate and not excessive.
D: Humid environments during the periods of remission do not directly impact autoimmune disorders unless the individual has a specific sensitivity to humidity.

Correct Answer: C

Rationale: The correct answer is C, veins deep in the lower extremities, due to stasis and immobility in the legs causing blood to pool and predispose to thrombus formation. This is known as deep vein thrombosis (DVT). Veins deep in the upper extremities (
A) are less commonly affected. The popliteal vein of the leg (
B) is a common site for DVT, but it is not the most commonly affected. Veins connected to the heart (
D) are arteries, not veins, and are not typically involved in thrombophlebitis.

Correct Answer: B

Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco is important to remove dried blood when the tongue is bitten during a seizure. This is crucial for preventing infection and promoting oral hygiene.

Choices A, C, and D are incorrect because the primary reason for mouth care in this case is to address the physical consequences of a seizure, such as tongue biting and potential injury, rather than thirst, tactile stimulation, or prevention of oral mucosal issues related to mouth breathing in a comatose patient.

Correct Answer: B

Rationale: The correct answer is B: Pink, frothy sputum. This is because pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. Furosemide IV is a diuretic that helps remove excess fluid from the body, including the lungs. Resolving pink, frothy sputum indicates that the treatment is effectively reducing the fluid in the lungs.

Incorrect choices:
A: Pedal edema - This refers to swelling in the feet and ankles, which is not directly related to pulmonary edema.
C: Jugular vein distention - This is a sign of heart failure, not specifically pulmonary edema.
D: Bradycardia - This is a slow heart rate and not a direct indicator of pulmonary edema resolution.