Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. A serum calcium level of 7.2mg/dl indicates hypocalcemia. Trousseau's sign is a clinical manifestation of hypocalcemia, characterized by carpal spasm induced by inflating a blood pressure cuff above systolic pressure. This occurs due to increased neuromuscular excitability from low calcium levels. Hegar's sign (B) is associated with pregnancy, Homan's sign (C) is a clinical test for deep vein thrombosis, and Goodell's sign (D) is a softening of the cervix during pregnancy. These signs are not relevant to a client with hypocalcemia.

Correct Answer: A

Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections. - Choice B: Cognitive problems, is not directly related to lymphocyte levels. - Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes. - Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.

Correct Answer: D

Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support. A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls. B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls. C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies. In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.

Correct Answer: C

Rationale: The correct answer is C: chronic biliary inflammation or obstruction. Biliary cirrhosis is a condition characterized by scarring of the liver due to long-term damage to the bile ducts. Chronic biliary inflammation or obstruction can lead to the build-up of bile in the liver, causing damage over time. Acute viral hepatitis (choice A) typically does not directly cause biliary cirrhosis. Alcohol hepatotoxicity (choice B) is more commonly associated with alcoholic liver disease rather than biliary cirrhosis. Hepatic failure with prolonged venous hepatic congestion (choice D) may lead to liver cirrhosis, but it is not specific to biliary cirrhosis.

Correct Answer: A

Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.