Correct Answer: D

Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.

Correct Answer: A

Rationale: The correct answer is A: emergency. In this scenario, the patient is experiencing difficulty in urination due to benign prostate hyperplasia (BPH), a condition that can lead to serious complications like acute urinary retention. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to relieve the obstruction caused by BPH. Given the urgency of the situation and the potential for acute complications, the surgery needs to be performed immediately to prevent further harm to the patient's health. Classifying this condition as an emergency ensures prompt intervention and prioritizes the patient's well-being. Summary: - B: C.urgent (not correct): While the surgery is time-sensitive, it does not require immediate intervention like in an emergency situation. - C: elective (not correct): Elective surgeries are planned in advance and are not typically performed in urgent situations like this one. - D: required (not correct): While the surgery is necessary for the patient's condition

Correct Answer: C

Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.

Correct Answer: C

Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.

Correct Answer: B

Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues. A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario. C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness. D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.