Correct Answer: A

Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications. Incorrect choices: B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture. C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority. D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.

Correct Answer: C

Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?” Rationale: 1. Involving the family and physician ensures a collaborative decision-making process. 2. It respects the client's autonomy and involves them in the decision-making process. 3. It promotes open communication and support from loved ones. 4. It addresses the client's concerns about continuing treatment based on family wishes. Summary: A: Refers to psychological support, but the client's primary concern is medical treatment decisions. B: Involves religious support, which may not align with the client's beliefs or address the medical decision. D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.

Correct Answer: A

Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.

Correct Answer: A

Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications. Incorrect choices: B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture. C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority. D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.

Correct Answer: A

Rationale: The correct answer is A: Provide positive feedback when he uses the word correctly. In individuals with expressive aphasia, positive reinforcement helps improve communication skills. Praising Mr. Reyea when he uses words correctly encourages continued effort and boosts confidence. This approach motivates him to communicate more despite his challenges. Summary of other choices: B: Waiting indefinitely for Mr. Reyea to verbally state needs is not practical and may lead to frustration. C: Suggesting permanent help at home assumes the disability cannot improve, which is not necessarily true for expressive aphasia. D: Helping the family to accept Mr. Reyea's inability to communicate verbally may hinder his progress and limit his social interactions.