Correct Answer: A

Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.

Correct Answer: D

Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put strain on the surgical incision site and increase the risk of complications. A: Incorrect, as the head of the bed should be elevated to reduce swelling and promote drainage. B: Incorrect, as deep breathing and coughing are important to prevent pneumonia and promote lung expansion. C: Incorrect, as swallowing may be difficult initially but should improve gradually.

Correct Answer: C

Rationale: The correct initial action is to choose C: Ask the patient about the facial grimacing with movement. This is important as the patient's non-verbal cues (facial grimacing) contradict their verbal pain report. By directly addressing the discrepancy, the nurse can gather more accurate information about the patient's pain experience and potentially identify any underlying issues causing the discrepancy. Proceeding to the next patient's room (A) without addressing the discrepancy would neglect the patient's needs. Assuming the patient does not want pain medicine (B) based solely on the verbal report without further assessment is premature. Administering pain medication (D) without clarifying the situation may lead to inappropriate or ineffective treatment. Therefore, option C is the most appropriate initial action to ensure comprehensive and individualized patient care.

Correct Answer: B

Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client. A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia. C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment. D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.

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.