Nutritional considerations as part of the nursing care plan would include all of the following except that:

Correct Answer: B

Rationale: Correct Answer: B: Calcium should be avoided Rationale: 1. Calcium is an essential mineral for bone health, especially important for individuals with limited mobility like Richard. 2. Avoiding calcium can lead to bone weakening and increase the risk of fractures. 3. Nursing care plans should include adequate calcium intake to support bone health. 4. Therefore, avoiding calcium is not a recommended nutritional consideration. Summary of Incorrect Choices: A: The diet should be semisolid to facilitate the passage of food - This is important for individuals with swallowing difficulties. C: The patient should be sitting in an upright position during feeding - This aids in proper digestion and reduces the risk of aspiration. D: Thick fluids should be encouraged to provide additional calories - Thick fluids may increase the risk of aspiration in patients with neurological conditions.

Correct Answer: A

Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.

Correct Answer: B

Rationale: The correct answer is B (AB). AB blood type is the rarest because it is a result of inheriting both A and B alleles, making it less common in the population. AB individuals can only receive blood from other AB individuals due to their unique antigens. Blood types A, B, and O are more common in the population, with O being the most common as it is the universal donor. Blood type A and B are more common than AB since they only require one allele for their respective antigens. Thus, the rarity of AB blood type is due to the inheritance of both A and B alleles, making it the least common among the choices provided.

Correct Answer: C

Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.

Correct Answer: A

Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.

Correct Answer: D

Rationale: The correct action for the nurse to take is to notify the physician stat (choice D). Firstly, the patient presents with painful bladder spasms and blood-tinged urine, indicating a potential complication post-TURP. This warrants immediate medical attention to assess for possible bladder injury or hemorrhage. Giving Demerol (choice A) or B&O suppository (choice B) may provide symptomatic relief but does not address the underlying issue. Warming the irrigation solution (choice C) is not a priority in this situation and does not address the potential serious complications. Notifying the physician immediately allows for prompt evaluation and appropriate intervention to address the patient's condition effectively.

Correct Answer: A

Rationale: The correct answer is A because shampooing the hair thoroughly helps remove oil and dirt, which can interfere with the CT scan results. By having clean hair, the scan can produce clearer images. Choice B is incorrect because some preparation is needed for a CT scan, especially regarding cleanliness. Choice C is incorrect as giving a cleansing enema and fluids until 8 AM is not necessary for a CT scan of the head. Choice D is incorrect as shaving the scalp and attaching electrodes are not part of routine preparation for a CT scan.

Correct Answer: B

Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the virus that causes genital warts. It is transmitted through sexual contact and is the most common sexually transmitted infection. Cytomegalovirus (A) does not cause genital warts. Herpes simplex virus type II (C) causes genital herpes, not warts. Human immunodeficiency virus (D) causes AIDS and weakens the immune system but does not directly cause genital warts.