Correct Answer: A

Rationale: The correct answer is A: Client's spouse. In the case of an unconscious client, the spouse is the primary source of information about the client's medical history, medications, allergies, and recent events. This information is crucial for providing appropriate care. Medical records may not be immediately accessible. Diagnostic tests provide limited historical information. Nursing assessment relies on the client's condition, which may not provide comprehensive information.

Correct Answer: C

Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes. Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.

Correct Answer: C

Rationale: The correct answer is C: Respiratory rate 36/min. In this case, the nurse should address the respiratory rate first due to the patient's chronic lung disease, indicating potential respiratory distress. High respiratory rate may signify hypoxia, infection, or worsening lung function, posing immediate life-threatening risks. Addressing this symptom promptly is crucial to prevent respiratory failure. Fever (A) and difficulty urinating (B) are important but not as urgent as addressing potential respiratory distress. Painful legs and feet (D) may indicate peripheral neuropathy related to diabetes, which is important but not as critical as addressing the respiratory issue.

Correct Answer: B

Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.

Correct Answer: B

Rationale: The correct answer is B: 2 to 3 weeks. Alopecia is a common adverse reaction to chlorambucil, a type of chemotherapy drug that can cause hair loss. Alopecia typically occurs around 2 to 3 weeks after the first administration of chlorambucil. This is because chemotherapy drugs affect rapidly dividing cells, including hair follicles. Hair loss is a well-known side effect of many chemotherapy drugs, and it is important for the nurse to educate the client about this potential side effect. Incorrect choices: A: Immediately - Hair loss does not occur immediately after the first administration of chlorambucil. C: 1 week - Hair loss typically occurs later than 1 week after starting chemotherapy. D: 1 month - While hair loss can occur within a month, it is more likely to happen sooner, around 2 to 3 weeks after starting the medication.