Correct Answer: B

Rationale: The correct answer is B: 2 to 3 weeks. Alopecia (hair loss) is a common adverse reaction of chlorambucil, typically occurring 2 to 3 weeks after the first administration. This is due to the drug's effect on rapidly dividing cells, including hair follicles. Immediate onset (Choice A) is unlikely as it takes time for the drug to affect hair growth. One week (Choice C) is too soon for alopecia to manifest. One month (Choice D) is too long as alopecia usually occurs earlier. Therefore, the correct window for alopecia onset after chlorambucil administration is 2 to 3 weeks.

Correct Answer: B

Rationale: The correct answer is B: heparin. Heparin is an anticoagulant used for immediate treatment of pulmonary embolism to prevent further clot formation. It acts quickly by inhibiting clotting factors. Warfarin (A) is used for long-term anticoagulation but has a slower onset. Dexamethasone (C) is a corticosteroid used for inflammation, not thrombosis. Protamine sulfate (D) is used to reverse the effects of heparin but is not indicated for initial treatment.

Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention. A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status. C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status. D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning findings such as abnormal kidney function, lack of voiding, and decreased oral intake, the nurse needs to move to the diagnosis step of the nursing process. This involves analyzing the data collected to identify the patient's health problems and risks. In this case, the nurse needs to determine potential underlying issues related to the kidney function abnormalities and lack of voiding, and formulate a nursing diagnosis based on the findings. Summary of other choices: B: Planning comes after diagnosis and involves setting goals and creating a plan of care. C: Implementation follows planning and involves carrying out the plan of care. D: Evaluation is the final step of the nursing process where the nurse assesses the effectiveness of the interventions implemented.