Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Positive reinforcement helps enhance communication skills in individuals with expressive aphasia. 2. Providing positive feedback when Mr. Reyea uses words correctly encourages him to continue trying to communicate. 3. It boosts his confidence and motivation, leading to improved verbal communication over time. Summary of why other choices are incorrect: B. Waiting indefinitely for Mr. Reyea to verbally state his needs may lead to frustration and hinder effective communication. C. Suggesting permanent help at home assumes Mr. Reyea's condition cannot improve, which is not necessarily true for expressive aphasia. D. Helping the family accept Mr. Reyea's communication challenges does not actively support his communication improvement and may limit his progress.

Correct Answer: D

Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.

Correct Answer: B

Rationale: The correct answer is B: Eat a diet high in protein and calories to optimize tissue repair. Rationale: 1. Protein is essential for tissue repair and healing, which can help counteract the effects of radiation therapy on the skin and swallowing function. 2. Calories are necessary for energy to support the body's healing processes during radiation therapy. 3. A diet high in protein and calories can help maintain overall nutritional status and promote recovery. Incorrect Choices: A: Washing the radiation site vigorously can further irritate the skin, leading to more complications. C: Cool compresses may not be suitable for radiation-induced skin reactions and may not address the underlying issue of dysphagia. D: Drinking warm fluids may not directly address the need for optimal tissue repair and healing.

Correct Answer: B

Rationale: The correct answer is B: 2.0mEq/L. Severe vomiting can lead to hypokalemia, characterized by flat T waves and ST segment depression on ECG. This is due to decreased potassium levels affecting cardiac repolarization. A potassium level of 2.0mEq/L is dangerously low and consistent with the ECG findings in this scenario. Choices A, C, and D have potassium levels that are not reflective of severe hypokalemia, therefore they are incorrect. Option A (4.0mEq/L) is within the normal range, option C (8.0mEq/L) is elevated, and option D (2.6mEq/L) is higher than the correct value of 2.0mEq/L.