Correct Answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (
Choice
B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (
Choice
C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (
Choice
D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

Correct Answer: A

Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (
Choice
D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (
Choice
B) may not effectively address the disruptive behavior. Removing the Bible from the client (
Choice
C) without addressing the underlying issue may escalate the situation further.

Correct Answer: C

Rationale: Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.

Correct Answer: D

Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (
Choice
A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (
Choice
B) and Hyponatremia (
Choice
C) are less likely to occur compared to hypokalemia in this condition.

Correct Answer: A

Rationale: The correct diet for a client with chronic cirrhosis is high calorie, low protein. Cirrhosis can lead to impaired protein metabolism, making it essential to limit protein intake. High-calorie foods help meet the client's energy needs.
Choice B (High protein, high calorie) is incorrect because high protein intake can worsen hepatic encephalopathy.
Choice C (Low fat, low sodium) is not the most appropriate diet for cirrhosis as the focus should be on calories and protein.
Choice D (High calorie, low sodium) does not address the need to restrict protein intake, which is crucial in cirrhosis.