Correct Answer: A

Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. "Post-trauma syndrome" encompasses the psychological and emotional distress following a traumatic event. Choice B: Psychological overreaction simplifies the client's experience and does not capture the severity or ongoing nature of the trauma symptoms. Choice C: Needs assistance coping with attack is vague and does not provide a specific diagnosis or acknowledge the clinical presentation of the client. Choice D: Mental distress related to being attacked is too broad and does not specify the specific syndrome or symptoms experienced by the client.

Correct Answer: C

Rationale: The correct answer is C: Acute pain. The patient's right femur fracture would likely cause significant pain. Treating the pain is a priority to ensure the patient's comfort and promote healing. Posttrauma syndrome (A) is more applicable for patients experiencing emotional distress following a traumatic event. Constipation (B) may be a concern due to immobility but is not as immediate as managing pain. Anxiety (D) may be present but addressing the acute pain would likely alleviate some anxiety as well.

Correct Answer: A

Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.

Correct Answer: B

Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.