Correct Answer: C

Rationale: The correct answer is C: Listen and show interest as the client expresses feelings. It is essential for the nurse to actively listen and show empathy towards the client's emotional distress. This approach demonstrates compassion, understanding, and support for the client during a vulnerable moment, which is crucial for the therapeutic relationship. By actively listening, the nurse can validate the client's emotions and provide a safe space for them to express their feelings. This can help the client feel heard and supported, leading to improved emotional well-being. Choices A, B, and D are incorrect: A: Continuing with the bath and telling the client not to worry dismisses the client's emotions and fails to address their underlying feelings of loneliness and isolation. B: Asking for a psychiatric consultation may not be necessary at this point, as the client's emotional distress can be effectively managed through therapeutic communication. D: Stating that the friends' behavior shows they aren't true friends is judgmental and unhelpful, as it does not address

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: C

Rationale: The correct answer is C because assessing the patient's pain level is the priority when caring for a patient with a brain tumor about to begin radiation treatments. Pain management is crucial in providing comfort and ensuring the patient's well-being during treatment. Teaching the patient about what to expect and addressing any pain promptly are essential steps in delivering effective care. Padding the side rails (choice A) is important for patient safety, but it is not the priority in this situation. Isolating the patient (choice D) is unnecessary unless there is a specific medical indication. Teaching the patient what to expect (choice B) is important but assessing and managing pain take precedence to ensure the patient's comfort and safety during treatment.

Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery. Incorrect choices: B: Hiccups - Hiccups are not a common side effect of Ketamine administration. C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions. D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids. Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.

Correct Answer: C

Rationale: The correct answer is C: Neck vein distention. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia, causing fluid overload. This can manifest as neck vein distention due to increased venous pressure. Tetanic contractions (A) and weight loss (B) are not typical complications of SIADH; tetany is more associated with hypocalcemia and weight loss is not a common manifestation. Polyuria (D) is actually the opposite of what is seen in SIADH, which is characterized by water retention and concentrated urine.