Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.

Correct Answer: A

Rationale: The correct answer is A: Facial tenderness. Sinus infections commonly present with facial tenderness due to the inflammation and pressure within the sinuses. This symptom is often accompanied by pain or pressure around the eyes, cheeks, and forehead. Photophobia (B) is more commonly associated with conditions like migraines or meningitis. Chest pain (C) is not a typical symptom of a sinus infection. Ear drainage (D) is more indicative of an ear infection rather than a sinus infection.

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning findings such as abnormal kidney function, lack of voiding, and decreased oral intake, the nurse needs to move to the diagnosis step of the nursing process. This involves analyzing the data collected to identify the patient's health problems and risks. In this case, the nurse needs to determine potential underlying issues related to the kidney function abnormalities and lack of voiding, and formulate a nursing diagnosis based on the findings. Summary of other choices: B: Planning comes after diagnosis and involves setting goals and creating a plan of care. C: Implementation follows planning and involves carrying out the plan of care. D: Evaluation is the final step of the nursing process where the nurse assesses the effectiveness of the interventions implemented.

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.

Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention. A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status. C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status. D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.