Correct Answer: C

Rationale: The correct answer is C: Drug Compliance. After a CVA (stroke), it is crucial for Mr. Dela Isla to understand and adhere to his prescribed medications. Medications help prevent further strokes and manage underlying conditions. Drug compliance ensures optimal treatment outcomes. Emergency Numbers (A) are important but not the priority post-stroke. Relaxation techniques (B) may be helpful but not as critical as medication adherence. Dietary prescription (D) is important but not as urgent as drug compliance in this scenario.

Correct Answer: A

Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.

Correct Answer: D

Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition. Incorrect choices: A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it. B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed. D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.

Correct Answer: D

Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.