The nurse would monitor the client for which of the following?

Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. This involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia. The nurse should monitor for this sign in clients at risk for low calcium levels. Hypoglycemia and hypokalemia have specific signs and symptoms not related to Trousseau's sign. Respiratory changes are nonspecific and may not be directly related to monitoring for low calcium levels.

Correct Answer: C

Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms. Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.

Correct Answer: C

Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.

Correct Answer: A

Rationale: The correct answer is A: Active natural immunity. The mother had chickenpox as a child, which triggered her immune system to produce antibodies, providing long-lasting protection. This is an example of active immunity because her immune system actively responded to the pathogen. Summary: B: Passive artificial immunity - This involves receiving pre-made antibodies, not produced by the individual's immune system. C: Passive natural immunity - This is acquired through placental transfer or breastfeeding, not through prior exposure to the pathogen. D: Active artificial immunity - This is acquired through vaccination, not through natural exposure to the pathogen.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.

Correct Answer: B

Rationale: The correct answer is B because a client's medical history of allergy to iodine or seafood is crucial for urinary diversion assessment to prevent potential adverse reactions during procedures involving contrast media or seafood-based medications. It is essential to ensure the client's safety and avoid any allergic reactions. Choice A is incorrect because assessing sexual function is not directly related to urinary diversion assessment. Choice C is also incorrect as urinary diversion does not typically affect nervous control. Choice D is irrelevant to the assessment of a client undergoing urinary diversion.

Correct Answer: C

Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals. Rationale: 1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect. 2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect. 3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.

Correct Answer: C

Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance. A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit. B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake. D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.