Correct Answer: B

Rationale: The correct answer is B: Eye movements. When assessing the oculomotor, trochlear, and abducens nerves, evaluating eye movements is crucial. This assessment includes checking the pupils for size, regularity, equality, light reactions, accommodation, and extraocular movements in various gaze positions. Tongue symmetry is primarily used to evaluate cranial nerve XII (hypoglossal nerve) function. Facial symmetry is a key indicator of cranial nerve VII (facial nerve) function. The corneal reflex assesses sensory afferents in cranial nerve V (trigeminal nerve) and motor efferents in cranial nerve VII (facial nerve).

Correct Answer: D

Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician. Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100°F should be reported to the physician as it could indicate infection.

Correct Answer: B

Rationale: The correct answer is 'The client states she is currently taking birth control pills.' This finding requires further teaching because being on birth control pills does not protect against sexually transmitted diseases (STDs), and the adolescent should be educated on the importance of using barrier methods (e.g., condoms) for STD prevention. Choices A, C, and D are not concerning. Choice A is a normal developmental milestone in adolescence. Choice C could indicate a positive lifestyle change, and choice D is a common complaint during this stage of development.

Correct Answer: C

Rationale: The correct answer is C: 'says 'Mine!' when playing with toys.' At the age of 2, children are in the stage of parallel play and are possessive of their belongings, hence saying 'Mine!' is an age-appropriate behavior. Building towers with blocks (choice A) involves more advanced motor skills and cognitive abilities, which are beyond what most 2-year-olds can do. Trying to color within the lines (choice B) requires fine motor skills that are typically not developed at age 2. Jumping rope (choice D) involves coordination and balance that are beyond the capabilities of a 2-year-old child.

Correct Answer: C

Rationale: The correct answer is 'when needs change.' It is crucial for the nurse to remain adaptable and adjust the plan promptly when the patient's needs or condition change. Choice A, 'halfway through the shift,' may not align with the timing of when needs actually change, making it less optimal for plan modifications. Choice B, 'at the end of the shift before the nurse reports off,' is too late to address evolving needs effectively. Choice D, 'after the top-priority tasks have been completed,' limits the nurse's ability to respond promptly to changing priorities, as needs may shift before all top-priority tasks are finished.