Correct Answer: C

Rationale: The correct answer is C because the resolution of paresthesia in the hands and feet is a common clinical manifestation of Vitamin B12 deficiency. Paresthesia is a neurological symptom associated with nerve damage due to B12 deficiency. When the client no longer experiences paresthesia, it indicates that the treatment has been effective in addressing the deficiency.

Choices A, B, and D do not directly relate to the improvement of Vitamin B12 deficiency symptoms. Weight gain and pink buccal mucosa may be positive outcomes but are not specific to B12 deficiency. Eating more iron-fortified cereals and stopping alcohol consumption do not directly address the neurological symptoms associated with B12 deficiency.

Correct Answer: A

Rationale: The correct rate is 480 mL/hr.
To calculate this, divide the total volume (200 mL) by the total time (25 minutes), then convert the time to hours (25 minutes ÷ 60 = 0.42 hours). Next, divide the volume by the time (200 mL ÷ 0.42 hours = 476.19 mL/hr), which is rounded up to 480 mL/hr. This rate ensures the client receives the prescribed 200 mL of NSS in 25 minutes.
Choice A is correct because it accurately calculates the infusion rate based on the given parameters. Other choices are incorrect as they do not provide the precise calculation needed for the correct rate.

Correct Answer: A

Rationale: The correct answer is A: Maintain IV fluid infusion and assess adequacy of hydration. In sickle cell crisis, hydration is crucial to prevent vaso-occlusive events. The client is at risk for dehydration due to increased respiratory rate and fever. Adequate hydration helps improve blood flow and oxygenation to prevent further complications. Continuous sedation (
B) is not the priority; pain management can be addressed after ensuring hydration. Inserting a Foley catheter (
C) may not be necessary unless there are specific indications. Endotracheal intubation (
D) is not indicated based on the client's current condition.

Correct Answer: C

Rationale: The correct answer is C because the client's cholesterol level is elevated at 200 mg/dl, HDL is low at 35 mg/dl, and triglycerides are high at 190 mg/dl. These results indicate a need for dietary modifications to improve the lipid profile and reduce the risk of cardiovascular events.


Choice A is incorrect because the cholesterol level is extremely low at 20 mg/dl, which is not a concern for dietary modifications.
Choice B is incorrect because the cholesterol level is within the normal range at 165 mg/dl.
Choice D is incorrect because although the triglycerides are high at 220 mg/dl, the cholesterol and HDL levels are not significantly elevated or reduced to warrant immediate dietary modifications.

Correct Answer: B

Rationale:
Correct
Answer: B


Rationale: The nurse should assist the client to identify the trigger situation and choose a coping strategy first because it addresses the root cause of the self-harming behavior in a client with borderline personality disorder. This approach helps the client develop healthier coping mechanisms to manage their anxiety and impulses. Restraining the client (
Choice
A) may escalate the situation and violate the client's autonomy. Sending the client to a crisis intervention unit (
Choice
C) may be necessary in severe cases but is not the first step in managing the client's anxiety. Advising the client to take an anxiolytic (
Choice
D) without addressing the underlying trigger and coping strategies may not be effective in the long term.