Correct Answer: B

Rationale: Jaundice in a client with liver cirrhosis is primarily caused by increased bilirubin levels. In liver cirrhosis, the impaired liver function leads to the accumulation of bilirubin in the blood, resulting in jaundice. Bilirubin is a yellow pigment produced from the breakdown of red blood cells, and its elevation is a common manifestation of liver dysfunction.

Correct Answer: A

Rationale: When educating a patient prescribed allopurinol for gout, the nurse should emphasize taking the medication with food to reduce the risk of gastrointestinal upset. It is important to instruct the patient to maintain adequate hydration by consuming plenty of fluids, preferably water, to help prevent kidney stone formation and facilitate the drug's effectiveness. Allopurinol does not provide immediate pain relief but rather works to lower uric acid levels over time, reducing the frequency of gout attacks.

Correct Answer: C

Rationale: The rapid, deep (Kussmaul) respirations in a patient with diabetic ketoacidosis indicate a metabolic acidosis, necessitating correction with a saline bolus to prevent hypovolemia, followed by insulin administration to facilitate glucose re-entry into cells. Oxygen therapy is not warranted as the increased respiratory rate is not due to hypoxemia but is compensatory in response to acidosis. Encouraging slow breathing or administering lorazepam would be inappropriate as they can worsen the acidosis by suppressing the compensatory respiratory effort.

Correct Answer: A

Rationale: The mother who took her children from school due to delusions of aliens poses a significant risk to her children and herself. This situation requires immediate attention to ensure the safety and well-being of all involved.

Correct Answer: A

Rationale: The correct instruction for a patient prescribed hydroxychloroquine, especially in the context of systemic lupus erythematosus (SLE), is to report any vision changes immediately. Hydroxychloroquine can potentially cause retinal damage, so prompt reporting and ophthalmologic evaluation are essential in preventing irreversible eye complications.