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: 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: A

Rationale: The correct answer is A: Disturbed thought processes. This is the problem statement because it identifies the specific nursing diagnosis that reflects the client's cognitive impairment. "Disturbed thought processes" directly addresses the issue the nurse is observing in the client. The other choices are not the problem statement. "Related to" is the etiology or cause of the problem, "Alzheimer’s disease" is the medical condition, and "Incoherent language" is the defining characteristic or evidence of the problem. Therefore, A is the correct answer as it clearly states the client's primary issue.

Correct Answer: B

Rationale: The correct answer is B because hyperkalemia presents with symptoms such as muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common sign due to potassium's effect on neuromuscular function. Diarrhea can lead to potassium loss. ECG changes, such as peaked T waves and widened QRS complexes, indicate cardiac involvement. Assessing for these symptoms helps monitor the severity of hyperkalemia and guide treatment. Other choices are incorrect because assessing for fever and chest pain (choice A) are not specific to hyperkalemia. Encouraging fluid restriction (choice C) may not directly address hyperkalemia. Preparing for a cardiac ultrasound (choice D) is not an immediate intervention for hyperkalemia.

Correct Answer: D

Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.

Correct Answer: C

Rationale: The correct answer is C: To rule out cholinergic crisis caused by Neostigmine. Edrophonium HCL is a fast-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis. If the patient's weakness improves after administration of edrophonium, it indicates that the weakness was due to myasthenia gravis and not cholinergic crisis caused by excessive neostigmine. Choice A is incorrect because there is no synergestic effect between neostigmine and edrophonium. Choice B is incorrect as resistance to neostigmine is not a valid reason for ordering edrophonium. Choice D is incorrect because edrophonium is used for differential diagnosis, not for confirming the diagnosis of myasthenia gravis.

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: A

Rationale: The correct answer is A because signs and symptoms listed are indicative of disseminated intravascular coagulation (DIC), which is a serious condition where blood clotting and bleeding occur simultaneously. Change in level of consciousness can indicate hypoperfusion from clotting in blood vessels. Tachypnea and tachycardia can result from tissue hypoxia. Petechiae are small red or purple spots on the skin due to bleeding under the skin. Choices B, C, and D are incorrect because they do not align with the typical signs and symptoms of DIC. Choice B suggests a possible myocardial infarction or acute coronary syndrome. Choice C indicates a possible thrombotic thrombocytopenic purpura (TTP) or acute limb ischemia. Choice D suggests a mix of symptoms that do not typically present together in DIC.

Correct Answer: B

Rationale: The correct answer is B: I.V. administration and urinary excretion. Lomustine is typically administered intravenously, allowing for rapid systemic distribution. The drug is metabolized in the liver and excreted primarily through the kidneys, thus the urinary route. This choice is correct as lomustine's pharmacokinetics align with this pattern. A: Oral administration and urinary - While some drugs are administered orally, lomustine is not typically given orally due to poor bioavailability. C: I.V. administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect. D: Oral administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.