Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications. Summary of why other choices are incorrect: B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario. C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions. D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: C

Rationale: The correct answer is C: Fat. Excessive ingestion of fat has been linked to autoimmunity due to its potential to trigger inflammation in the body, which can disrupt the immune system's balance and lead to autoimmune responses. High-fat diets have been associated with increased production of pro-inflammatory molecules, impacting immune function negatively. Protein (choice A) is essential for immune function, vitamin A (choice B) supports immune responses, and zinc (choice D) is crucial for immune system regulation. However, excessive intake of these nutrients typically does not directly lead to autoimmunity like excessive fat consumption does.

Correct Answer: C

Rationale: The correct answer is C: Cold sensitivity. Severe anemia leads to decreased oxygen delivery to tissues, causing symptoms like pallor, fatigue, and dyspnea on exertion due to the body compensating for low oxygen levels. Cold sensitivity is not a common symptom associated with anemia. The other choices are directly related to severe anemia due to the lack of oxygen delivery to tissues.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.

Correct Answer: C

Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance. A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit. B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake. D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.

Correct Answer: C

Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals. Rationale: 1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect. 2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect. 3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.

Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening is crucial when working with a dying client and their family as it involves fully concentrating, understanding, responding, and remembering what is being said. This technique helps the nurse show empathy, build trust, and provide emotional support. By actively listening, the nurse can better understand the client's needs and concerns, which is essential in end-of-life care. Reflection (A) involves paraphrasing what the client said, which may not always be appropriate in this sensitive situation. Clarification (B) and Interpretation (C) involve adding one's own understanding or perspective, which can be intrusive and may not align with the client's feelings or beliefs.