Correct Answer: B

Rationale: In clients with dementia, restlessness and agitation are important symptoms that the nurse should address first. These symptoms can indicate underlying issues such as pain, discomfort, or unmet needs, and addressing them promptly can prevent complications. Psychosocial stressors may contribute to the client's condition but should not be the initial priority. Frequent wandering at night and urinary incontinence are also common in dementia but do not pose immediate risks compared to restlessness and agitation.

Correct Answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

Correct Answer: A

Rationale: The correct answer is A: Diabetic ketoacidosis and dehydration. Untreated hyperglycemia can lead to diabetic ketoacidosis, a serious complication characterized by high blood sugar, the presence of ketones in the urine, and acidosis. Dehydration is also a common complication of untreated hyperglycemia. Choices B, C, and D are incorrect because hypoglycemia and hypertension are not typical complications of untreated hyperglycemia. Infection and liver failure, as well as pulmonary edema and electrolyte imbalance, are also not direct complications of untreated hyperglycemia.

Correct Answer: A

Rationale: The correct answer is A: Excessive thirst and fruity breath odor. Diabetic ketoacidosis presents with these early signs due to ketone buildup in the body. Choice B, weight loss and increased urination, are more characteristic of uncontrolled diabetes but not specific to diabetic ketoacidosis. Choice C, nausea and vomiting, can occur in diabetic ketoacidosis but are not as early or specific as excessive thirst and fruity breath odor. Choice D, hypoglycemia and fatigue, are not typical signs of diabetic ketoacidosis; rather, diabetic ketoacidosis usually presents with hyperglycemia.

Correct Answer: A

Rationale: Administering oxygen and calling for emergency assistance are the immediate priorities when managing a suspected pulmonary embolism. Oxygen helps support the patient's respiratory function, while emergency assistance is crucial for further evaluation and treatment. Positioning the patient in a prone position or giving fluids can worsen the condition by impeding blood flow. Administering anticoagulants may be part of the treatment plan but is not the initial response. Thrombolytics and chest physiotherapy are not first-line treatments for suspected pulmonary embolism and can even be harmful without prior evaluation.