Correct Answer: A

Rationale: The correct answer is A: Client’s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.

Correct Answer: A

Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.

Correct Answer: D

Rationale: The correct answer is D: Assess swallowing reflex. This is crucial for a patient with Bell's Palsy as it can affect their ability to swallow properly, leading to inadequate nutrition intake. By assessing the swallowing reflex, the nurse can determine if the patient is at risk of aspiration or difficulty in eating, which directly impacts their nutrition status. Monitoring meal trays (A) may not provide accurate information on actual food intake. Checking weights (B) only gives limited information on nutrition status. Measuring intake and output (C) is important for fluid balance but may not directly reflect adequate nutrition intake.

Correct Answer: B

Rationale: The correct answer is B: A hypothermia blanket. This is important because hypothermia can lead to complications such as shivering, increased risk of infection, and altered drug metabolism. Checking for the hypothermia blanket ensures Mrs. Zeno's temperature is regulated, promoting safety. A: A tracheostomy set is not directly related to Mrs. Zeno's immediate safety unless she has a tracheostomy in place. C: An intravenous set-up is important for administering medications, fluids, or blood products, but it is not directly related to Mrs. Zeno's safety at the bedside. D: A syringe and edrophonium HCl(Tensilon) is specific to a diagnostic test for myasthenia gravis, which may not be relevant to Mrs. Zeno's current condition or safety.