Correct Answer: A

Rationale: Hepatic encephalopathy is the most likely condition causing confusion and disorientation in a client with liver cirrhosis. This condition is a common complication of liver cirrhosis and is characterized by cognitive impairment due to elevated ammonia levels in the blood. The build-up of ammonia affects brain function, leading to symptoms such as confusion, disorientation, and altered consciousness.

Correct Answer: C

Rationale: The correct answer is C. Clients with liver cirrhosis should avoid acetaminophen because it can cause further liver damage. Acetaminophen is metabolized in the liver, and in individuals with liver disease, it can lead to liver toxicity. Therefore, clients with liver cirrhosis should use alternative pain medications that do not affect the liver, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids as prescribed by their healthcare provider.

Correct Answer: B

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. To minimize this risk, patients with thrombocytopenia should avoid activities that can cause injury or bleeding, such as intramuscular injections. Encouraging light exercise can be beneficial, as it promotes circulation without increasing the risk of trauma. Aspirin should be avoided as it can further impair platelet function. Additionally, using a soft toothbrush for oral care is recommended to prevent gum bleeding in patients with thrombocytopenia.

Correct Answer: C

Rationale: The rapid, deep (Kussmaul) respirations in a patient with diabetic ketoacidosis indicate a metabolic acidosis, necessitating correction with a saline bolus to prevent hypovolemia, followed by insulin administration to facilitate glucose re-entry into cells. Oxygen therapy is not warranted as the increased respiratory rate is not due to hypoxemia but is compensatory in response to acidosis. Encouraging slow breathing or administering lorazepam would be inappropriate as they can worsen the acidosis by suppressing the compensatory respiratory effort.

Correct Answer: C

Rationale: The priority action for the nurse when time is limited is to focus on essential teaching. In this scenario, the patient should be educated on how to self-monitor glucose levels and administer medications to control glucose levels. While diet, exercise, medications, and potential complications are important topics for further education, these can be addressed through appropriate referrals and future teaching sessions.