Correct Answer: D

Rationale: In severe depression, the priority nursing diagnosis is safety. Individuals with severe depression are at risk of self-harm or suicide. Ensuring the client's safety by implementing measures to prevent harm to themselves or others is crucial. While nutrition, elimination, and activity are important aspects of care, ensuring the client's immediate safety takes precedence in this situation.

Correct Answer: D

Rationale: The correct answer is D because the ultimate goal of family planning is not solely to prevent pregnancies but to promote individual and family well-being. Family planning encompasses various aspects such as helping individuals and families make informed choices about the number and spacing of their children, access to healthcare services, and overall reproductive health. Option A is correct as making family planning services available to those who need them is essential for promoting reproductive health. Option B is also correct as it emphasizes the role of parents in making decisions about having children. Option C is correct as family planning indeed aims to improve the welfare of individuals and families. Therefore, option D is not correct as the ultimate goal of family planning is not limited to preventing pregnancies, but it includes broader aspects of promoting health and well-being.

Correct Answer: C

Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.

Correct Answer: C

Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.

Correct Answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.