Correct Answer: A

Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances. Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.

Correct Answer: A

Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue. Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.

Correct Answer: D

Rationale: The correct answer is D: An adrenal adenoma. Adrenal adenoma is the most common cause of primary hyperaldosteronism, also known as Conn's syndrome. Adrenal adenomas are benign tumors that cause overproduction of aldosterone, leading to increased sodium retention and potassium excretion. This results in hypertension and hypokalemia. Excessive sodium intake (A) and deficient potassium intake (B) are not direct causes of hyperaldosteronism. A pituitary adenoma (C) is associated with other hormone imbalances, such as Cushing's syndrome or acromegaly, but not hyperaldosteronism.

Correct Answer: A

Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight. - Choice B is about interpreting physical signs, not client data validation. - Choice C involves documenting objective findings, not validating client information. - Choice D pertains to a client's complaint, not necessarily requiring validation.

Correct Answer: C

Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.