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 a range of symptoms following a traumatic event, such as flashbacks, anxiety, and emotional distress. The other choices are incorrect because they are either too vague (B: Psychological overreaction) or do not capture the specific nature of the client's symptoms (C: Needs assistance coping; D: Mental distress). Therefore, option A is the most appropriate diagnosis based on the client's presentation.

Correct Answer: D

Rationale: The correct answer is D: 4, 5, 2006. Upon admission, a patient with allergies to bee stings may exhibit tachycardia (increased heart rate) due to an allergic reaction. Respiratory stridor (high-pitched wheezing) may occur as a sign of airway inflammation. Retinal hemorrhage and dyspnea (difficulty breathing) are not typically associated with bee sting allergies. Pallor and numbness/tingling are also not common symptoms in this scenario. Therefore, choices A, B, and C are incorrect.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs. Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe. In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.

Correct Answer: B

Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.

Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. A serum calcium level of 7.2mg/dl indicates hypocalcemia. Trousseau's sign is a clinical manifestation of hypocalcemia, characterized by carpal spasm induced by inflating a blood pressure cuff above systolic pressure. This occurs due to increased neuromuscular excitability from low calcium levels. Hegar's sign (B) is associated with pregnancy, Homan's sign (C) is a clinical test for deep vein thrombosis, and Goodell's sign (D) is a softening of the cervix during pregnancy. These signs are not relevant to a client with hypocalcemia.