Correct Answer: C

Rationale: The correct answer is C: Observing for leakage of urine or stool from the anastomosis. This is crucial in nursing management post-urinary diversion procedure to prevent complications such as infection, dehydration, and skin breakdown. Leakage can indicate issues with the surgical site integrity and requires prompt intervention. A: Placement of IV and central venous pressure lines is important but not as critical as monitoring for leakage from the anastomosis. B: Administering cleansing enemas may be necessary for certain procedures but is not the most important factor in this case. D: Assessing the client's ability to manage self-catheterization is important for long-term care but does not take precedence over monitoring for potential complications like leakage. In summary, option C is the most important factor as it directly impacts the client's immediate post-operative care and helps prevent serious complications.

Correct Answer: B

Rationale: The correct answer is B: Drowsiness. Muscle relaxants can cause drowsiness as a common side effect due to their sedative properties. This can impair alertness and coordination, so it's crucial for the patient to be aware of this potential effect. Choice A, hypoglycemia, is not typically associated with muscle relaxants. Choice C, hypotension, is more commonly linked to medications like antihypertensives. Choice D, dyspnea, which is difficulty breathing, is not a common side effect of muscle relaxants. Therefore, the nurse should primarily focus on educating the patient about the potential side effect of drowsiness.

Correct Answer: C

Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect. Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect. Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication. Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.

Correct Answer: C

Rationale: The correct answer is C: Counselling on alternate therapies. Chronic tension headaches may be exacerbated by stress or other psychological factors, making counseling an appropriate intervention. The nurse can explore relaxation techniques, stress management strategies, or cognitive-behavioral therapy to help the client manage their headaches. A: Instructing the client to monitor for signs of bruising or bleeding is unrelated to tension headaches and not a priority in this situation. B: Suggesting eating and swallowing techniques that reduce the potential for aspiration is not relevant to tension headaches and is not the most appropriate intervention. D: Advising the client to change sleeping positions frequently may help with other types of headaches but is not the most effective strategy for managing chronic tension headaches.

Correct Answer: B

Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.