Correct Answer: C

Rationale: The correct answer, indicated as C.
Rationale: Wrapping the blood pressure cuff snugly around the arm is correct, as the cuff needs to be secure to ensure an accurate reading. Centering the cuff bladder over the brachial artery is correct, as this is necessary for accurate blood pressure measurement. Placing the client's arm above the level of the heart is incorrect. The arm should be at heart level to ensure the accuracy of the reading. If the arm is elevated, it could result in a falsely low reading. Checking the instrument gauge to ensure the reading starts at zero is correct. This step is important to ensure the accuracy of the measurement.

Correct Answer: A

Rationale: The correct answer, indicated as A.
Rationale: Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another. While checking medications is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min).
Therefore, notifying the doctor of bradycardia is not appropriate in this case.

Correct Answer: D

Rationale: The correct answer, indicated as D.
Rationale: Assigning a private room may increase isolation, which is not conducive to a therapeutic environment. Tucking bedcovers over the client’s hands and arms could be a restrictive action, not appropriate for suicide prevention. Removing utensils is not necessary unless the client has direct access to harmful objects. Inspecting personal belongings ensures that the client does not have items that could be used for self-harm, which is a key suicide precaution.

Correct Answer: A

Rationale: The correct answer, indicated as A.
Rationale: Antisocial personality disorder is characterized by disregard for rules and the rights of others. Clients with this disorder often challenge authority and refuse to follow rules. Schizotypal personality disorder involves eccentric behavior and thinking, but it is not associated with defiance of rules. Histrionic personality disorder is characterized by attention-seeking behavior, not by defiance of rules. Narcissistic personality disorder involves a sense of entitlement and superiority, but it does not necessarily involve direct defiance of rules.

Correct Answer: 0.7

Rationale: The correct answer, indicated as 0.7.
Rationale:
To determine how many mL to administer, use the formula: mL = Desired Dose / Available Dose per mL. mL = 35 mg / 50 mg/mL = 0.7 mL. Thus, the nurse should administer 0.7 mL of diphenhydramine.