Correct Answer: A

Rationale: A respiratory rate of 10/min is below the normal range (12-20/min) and indicates potential magnesium sulfate toxicity, which can lead to respiratory depression or arrest. This finding should be reported immediately to the provider, and the infusion may need to be stopped.
Choice B is wrong because a blood pressure of 150/90 mm Hg, while elevated, is not unexpected in preeclampsia and does not indicate immediate toxicity; it should be monitored, but it is not the priority.
Choice C is wrong because a urine output of 40 mL/hr is within the acceptable range (at least 30 mL/hr) for a client receiving magnesium sulfate and does not indicate renal compromise.
Choice D is wrong because deep tendon reflexes of 2+ are normal and do not suggest magnesium toxicity, which would present with absent or diminished reflexes.

Correct Answer: A

Rationale: Increasing fluid intake to 2 to 3 liters daily helps prevent uric acid crystal formation in the kidneys and promotes excretion, reducing gout flare-ups while taking allopurinol.
Choice B is incorrect because high-purine meals (e.g., red meat, shellfish) should be avoided, as they increase uric acid levels, counteracting allopurinol's effect.
Choice C is incorrect because allopurinol takes weeks to reduce uric acid levels and does not provide immediate joint pain relief; acute attacks require other treatments like NSAIDs.
Choice D is incorrect because, while ice may help during an acute gout attack, it is not directly related to allopurinol use and is not the priority instruction.

Correct Answer: A

Rationale: Inability to sit still for prolonged periods is a hallmark symptom of ADHD, reflecting hyperactivity and impulsivity, especially in children and some adults.
Choice B is incorrect because a persistent sad mood is more associated with depression, not ADHD.
Choice C is incorrect because recurrent intrusive thoughts are characteristic of obsessive-compulsive disorder, not ADHD.
Choice D is incorrect because hypersomnia is not typical; ADHD may cause sleep difficulties due to hyperactivity, but not excessive sleep.

Correct Answer: C

Rationale:
Choice A is wrong because it is not the most urgent question to ask the client. While it is important to assess the client's social relationships and possible peer rejection, this can be done after addressing the client's safety and mental status.
Choice B is wrong because it is not relevant to the client's current condition and might make the client feel defensive or stigmatized. The nurse should avoid asking questions that imply blame or judgment and focus on the client's strengths and coping skills. This is the priority question for the nurse to ask the client because it assesses the client's risk for suicide, which is a serious and potentially life-threatening complication of conduct disorder. The nurse should use a direct and nonjudgmental approach when asking about suicidal ideation and plan.
Choice D is wrong because it is not appropriate for the nurse to ask the client in an emergency department setting. This question might imply that the client is responsible for their conduct disorder, which is a complex and multifactorial mental health condition. The nurse should collaborate with the client and their family to develop a behavior management plan that involves positive reinforcement, limit setting, and consistent consequences.

Correct Answer: C

Rationale: Stool positive for occult blood indicates potential gastrointestinal bleeding, a serious adverse effect of enoxaparin (a low-molecular-weight heparin), requiring immediate reporting to the provider.
Choice A is incorrect because a hemoglobin of 10 g/dL is low but not critical unless accompanied by signs of active bleeding; it should be monitored.
Choice B is incorrect because a platelet count of 100,000/mm3 is low but not immediately concerning unless trending downward or associated with bleeding.
Choice D is incorrect because INR is not used to monitor enoxaparin; it is relevant for warfarin therapy, and 1.2 is within normal limits.