Correct Answer: D

Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.

Correct Answer: C

Rationale: The correct answer is C: Assess apical heart before administering digitalis. This is important because digitalis can slow down the heart rate, so it is crucial to monitor the client's heart rate before giving the medication to prevent further decrease in cardiac output. Encouraging activities that engage the Valsalva maneuver (A) is contraindicated in clients with congestive heart failure as it can lead to increased intra-thoracic pressure and decreased venous return, worsening cardiac output. Encouraging the client to perform exercises (B) may also increase cardiac workload and exacerbate symptoms. Offering small frequent feedings (D) is generally beneficial for clients with congestive heart failure to prevent overeating and promote easier digestion, but it does not directly address the decreased cardiac output concern in this scenario.

Correct Answer: C

Rationale: The correct answer is C: limit daily alcohol intake. This is crucial for clients with cirrhosis as alcohol can exacerbate liver damage. Limiting alcohol intake helps prevent further harm to the liver and promotes overall health. Supplementation with multivitamins (choice A) can be beneficial, but not as essential as avoiding alcohol. Taking sleeping pills (choice B) may worsen liver function and is not recommended. Limiting contact at all times (choice D) is irrelevant to managing cirrhosis.

Correct Answer: D

Rationale: The correct answer is D: Whisper voice test. This test is used as an initial screening for hearing loss because it is simple, quick, and easily administered by a nurse. The nurse would whisper words or numbers at a specific distance from the patient to assess their ability to hear and repeat the whispered sounds accurately. This test provides a quick indication of potential hearing impairment. The other choices are incorrect: A: Romberg test assesses balance and not hearing. B: Caloric test evaluates the vestibular system, not hearing. C: Otoscopic examination is used to examine the ear canal and tympanic membrane, not to screen for hearing loss.

Correct Answer: C

Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway. Incorrect choices: A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure. B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions. D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure. Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.