Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?

Correct Answer: D

Rationale: Slow pupil reaction and rising systolic BP post-stroke indicate increased ICP (D), a common complication. Spinal (A) or hypovolemic shock (C) don't apply. Herniation (B) is a result. D is correct. Rationale: ICP from edema or bleeding requires urgent focus, per stroke management protocols, to prevent further brain damage.

Correct Answer: C

Rationale: In Maslow's Hierarchy, physiologic needs form the lowest level, encompassing essentials like air, water, food, and shelter required for survival. These foundational needs must be met before higher levels like safety, love, or self-esteem can be addressed, as a person cannot focus on security or relationships if starving or dehydrated. For example, a client struggling to breathe prioritizes oxygen over emotional support, illustrating this hierarchy's practical application in nursing. Misplacing higher needs below physiologic ones ignores human survival instincts, making this the correct baseline for assessing client priorities in care planning.

Correct Answer: C

Rationale: Explaining that viruses must enter living cells to reproduce is true and fundamental, distinguishing them from bacteria. Viruses lack cellular machinery, relying on host cells, unlike Candida, a fungus. They aren't the most common infectious agents universally, nor primarily intestinal. This fact educates the client accurately, aiding understanding of viral infections like flu, a key nursing teaching point.

Correct Answer: B

Rationale: The diaphragm separates thoracic and abdominopelvic cavities, aiding breathing. Ribs and sternum encase, stomach resides below. Nurses use this in respiratory assessments.

Correct Answer: A

Rationale: Rectal temperature is contraindicated post-myocardial infarction due to vagal stimulation risking cardiac complications, unlike in Parkinson's, seizures, or neuropathy. Nurses avoid this for safety.