Correct Answer: C

Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.

Correct Answer: C

Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.

Correct Answer: B

Rationale: Fludrocortisone replacement in Addison's disease involves mimicking the action of aldosterone, a mineralocorticoid that causes the retention of sodium and water. Excessive retention of sodium and water can lead to weight gain. Therefore, a sudden increase in weight, especially a significant amount like 6 pounds in one week, can indicate an overdose of fludrocortisone. Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not typically associated with excessive fludrocortisone replacement.

Correct Answer: D

Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.

Correct Answer: B

Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly. Choices A, C, and D are incorrect. Choice A is wrong as the voice should be whispered, not spoken in a soft tone. Choice C is inaccurate because a distance of 10 feet is too far for precise testing. Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.