Correct Answer: A

Rationale: A. Measuring abdominal girth every 4 to 8 hours is important to monitor for signs of fluid accumulation in the abdominal cavity, indicating potential fluid volume deficit.

Correct Answer: B

Rationale: The renal system plays a crucial role in regulating blood pressure through various mechanisms. Renin is an enzyme released by the kidneys in response to low blood pressure or low blood volume. Renin acts on angiotensinogen to convert it into angiotensin I, which is further converted into angiotensin II by angiotensin-converting enzyme (ACE) in the lungs. Angiotensin II is a potent vasoconstrictor, leading to an increase in blood pressure by constricting blood vessels. Additionally, angiotensin II stimulates the release of aldosterone, a hormone that promotes sodium and water retention in the kidneys, leading to an increase in blood volume and further elevating blood pressure.
Therefore, the release of renin by the renal system ultimately leads to an increase in blood pressure.

Correct Answer: D

Rationale: An ischemic stroke occurs when the blood supply to a part of the brain is obstructed, typically by a thrombus (a blood clot that forms in a blood vessel and remains attached to its place of origin) or an embolus (a blood clot that travels from a different part of the body and becomes lodged in a blood vessel in the brain). Another cause of ischemic stroke can be stenosis, which is the narrowing of a blood vessel, restricting blood flow to the brain. When the brain does not receive sufficient oxygen and nutrients due to the blockage, brain cells can be damaged or die, leading to a stroke. Ischemic strokes account for the majority of strokes and are essential to manage promptly to minimize brain damage and long-term disability.

Correct Answer: A

Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen™). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.

Correct Answer: A

Rationale: Asking the patient to clench their teeth is a common way to assess muscle strength in the face, particularly the muscles involved in the jaw. Clenching the teeth engages the muscles responsible for this action, such as the masseter muscle. Assessing the ability to clench the teeth provides insight into the strength and function of these facial muscles.