Correct Answer: B

Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.

Correct Answer: C

Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own. Incorrect Answers: A: Purplish stools - This is not a common side effect of lymphangiography. B: Redness of the upper part of the feet - Redness is not typically associated with this procedure. D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.

Correct Answer: D

Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.

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: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery. Incorrect choices: B: Hiccups - Hiccups are not a common side effect of Ketamine administration. C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions. D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids. Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.