Correct Answer: A

Rationale: The correct answer is A: A rapid, thready pulse. After paracentesis, rapid removal of ascitic fluid can lead to a decrease in intravascular volume, causing hypovolemia and subsequent compensatory mechanisms like tachycardia (rapid pulse). This is a crucial sign that the nurse should monitor for early detection of hypovolemia. B: Decreased peristalsis is not directly related to paracentesis and is not an immediate concern post-procedure. C: Respiratory congestion is not a common complication of paracentesis and is not the most immediate concern. D: An increased temperature is not a typical response to paracentesis and is not a priority observation post-procedure.

Correct Answer: C

Rationale: The correct answer is C: Serum calcitonin level. Smoking can elevate serum calcitonin levels due to the effect of nicotine. However, an elevated serum calcitonin level is not a general indicator of cancer. Step 1: Understand that smoking can increase serum calcitonin levels. Step 2: Recognize that elevated serum calcitonin levels are not specific to cancer and can be influenced by other factors. Step 3: Differentiate between a marker that is specific to cancer (such as carcinoembryonic antigen) and one that can be affected by smoking but not necessarily indicative of cancer (serum calcitonin). Thus, while smoking can elevate serum calcitonin levels, it is not a reliable indicator of cancer.

Correct Answer: D

Rationale: The correct answer is D: Refer the client to the American Cancer Society’s Reach for Recovery program or another support program. This choice is the best option as it provides the client with additional support and resources specifically tailored to individuals coping with cancer and mastectomy. The Reach for Recovery program offers emotional support, education, and practical assistance which can immensely benefit the client during this challenging time. A: Involving the client's spouse or partner is important, but support programs like Reach for Recovery can offer specialized assistance that may not be fully covered by the spouse's support alone. B: While proceeding with the next phase of treatment is important, emotional support and coping mechanisms are equally crucial, which support programs can provide. C: Asking the client to remain cheerful may put pressure on her and may not address her emotional needs adequately, unlike a support program that is designed to provide comprehensive support.

Correct Answer: C

Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion. Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.