Choice A reason: Disseminated intravascular coagulation (DIC) is a condition characterized by both excessive clotting and excessive bleeding. The clotting cascade is inappropriately activated throughout the body, leading to the formation of numerous small blood clots in the blood vessels. These clots consume clotting factors and platelets, which can then lead to excessive bleeding. This paradoxical combination of thrombosis and bleeding is a hallmark of DIC.

Choice B reason: In DIC, platelet consumption exceeds production. The formation of numerous clots uses up platelets faster than they can be produced, which can result in thrombocytopenia and bleeding. Therefore, a progressive increase in platelet production is not an expected finding in DIC.

Choice C reason: Immediate sodium and fluid retention is not a feature of DIC. This condition primarily involves the clotting and bleeding mechanisms, not fluid balance or sodium levels.

Choice D reason: In DIC, clotting factors are consumed in the formation of numerous clots. This leads to a deficiency of clotting factors, contributing to the bleeding tendency seen in this condition. Increased clotting factors would not be expected in a patient with DIC.

Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.

Choice A reason: Russell's traction involves the use of a sling under the knee to apply a pulling force on the femur. This helps in aligning and stabilizing the fractured femur, allowing for proper healing. The sling supports the leg, while weights provide the necessary traction force.

Choice B reason: A cervical halter is used in cervical traction to relieve muscle spasms and align the cervical spine, not in Russell's traction. This type of traction is not related to treating femur fractures.

Choice C reason: A pelvic girdle belt is used in pelvic traction to relieve lower back pain and stabilize pelvic fractures, not in Russell's traction. Russell's traction specifically pertains to femur fractures.

Choice D reason: Skeletal pins are used in skeletal traction, where pins are inserted into the bone to apply direct traction. Russell's traction, however, does not use skeletal pins; it uses a sling and weights to apply traction.

Choice A reason: While gowns may be part of the precautions, they are not sufficient alone for preventing the spread of TB, which is transmitted via airborne particles.

Choice B reason: Placing the client in a private room with a special ventilation system is crucial for preventing the spread of TB. The special ventilation system, typically a negative pressure room, ensures that airborne particles do not escape into other areas, thereby protecting staff and other patients.

Choice C reason: A semi-private room with another patient requiring droplet precautions is inappropriate for a TB patient, as TB requires strict airborne precautions to prevent transmission.

Choice D reason: Removing personal protective equipment in the hallway increases the risk of contaminating the hallway and spreading TB. PPE should be removed inside the room or anteroom to contain potential contaminants.

Choice A reason: Allowing the client to move around the room unsupervised can lead to falls, as Ménière’s disease can cause sudden episodes of vertigo and imbalance.

Choice B reason: Strict bed rest is usually not required for clients with Ménière’s disease. Encouraging mobility with assistance is typically more appropriate.

Choice C reason: Asking the client to call for assistance helps prevent falls and ensures the client's safety. Ménière’s disease often causes vertigo, and assistance is necessary to prevent injuries.

Choice D reason: This response does not address the client's safety concerns and may lead to misunderstanding the risks associated with ambulation in Ménière’s disease.

Choice A reason: Fresh fruits and vegetables can harbor bacteria and other pathogens that pose a significant infection risk to neutropenic clients. It's advisable to avoid these foods unless they are cooked or properly washed and peeled.

Choice B reason: Avoiding crowded places is essential for neutropenic clients because their immune system is weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to infectious agents.

Choice C reason: Participating in gardening is not recommended as it exposes neutropenic clients to soil bacteria and fungi, which can cause infections. Activities should be chosen carefully to minimize infection risk.

Choice D reason: Taking temperature weekly is not adequate for neutropenic clients. Daily temperature monitoring is important for early detection of infections, which can progress rapidly in immunocompromised individuals.

Choice A reason: Inserting an indwelling catheter can increase the risk of urinary tract infections, which is particularly dangerous for immunosuppressed clients. Monitoring for sediment can be done through less invasive methods.

Choice B reason: Taking the client's temperature once per shift may not be frequent enough. More frequent monitoring is recommended to detect early signs of infection.

Choice C reason: Providing fresh fruit, while beneficial for preventing constipation, can pose an infection risk due to potential contamination. Alternatives like canned or cooked fruits should be considered.

Choice D reason: Limiting the number of health care workers entering the room reduces the risk of introducing infections to the immunosuppressed client. This is a key measure to protect clients with weakened immune systems.

Choice A reason: Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not an appropriate infection control measure. Used tissues should be disposed of immediately in a proper waste receptacle to prevent the spread of tuberculosis bacteria.

Choice B reason: Sputum cultures should be provided more frequently than every 6 weeks to monitor the effectiveness of the treatment and to confirm when the client is no longer infectious. Monthly cultures are typically recommended until the patient shows no signs of active infection.

Choice C reason: Consuming alcohol in moderation while taking antituberculosis medications is not advised. Alcohol can interfere with the effectiveness of the medications and may also exacerbate potential side effects, such as liver toxicity, especially with medications like isoniazid and rifampin.

Choice D reason: The correct answer is d because wearing a mask while out or around crowds of people helps prevent the spread of tuberculosis. TB is an airborne disease, and wearing a mask reduces the risk of transmitting the infection to others.

Choice A reason: Feeding the client soft foods is not necessary after cataract surgery. Cataract surgery does not affect the client's ability to eat regular foods, and a normal diet can be resumed unless otherwise instructed by the healthcare provider.

Choice B reason: Positioning the client on the affected side is contraindicated after cataract surgery because it can increase pressure on the eye and disrupt the healing process. Clients are usually advised to avoid sleeping on the side of the operated eye to prevent complications.

Choice C reason: It is not necessary for the client to remain in bed for 3 days following cataract surgery. Clients are encouraged to resume normal activities as tolerated, but they should avoid strenuous activities and heavy lifting to prevent increased intraocular pressure.

Choice D reason: The correct answer is d because wearing dark glasses while outdoors helps protect the eyes from bright light and UV rays, which can cause discomfort and harm the healing eye after cataract surgery.

Choice A reason: Squamous cell carcinoma commonly occurs on sun-exposed areas such as the face, ears, neck, and hands, but not necessarily the trunk. It is important to emphasize the role of sun exposure in the development of this type of skin cancer.

Choice B reason: Radiation therapy is used in the treatment of certain types of skin cancer, but it is not typically the first choice for metastatic skin cancer. Other treatments, such as surgery, immunotherapy, or targeted therapy, are often preferred depending on the type and stage of skin cancer.

Choice C reason: The correct answer is c because sun exposure, especially during childhood, significantly increases the risk of developing skin cancer later in life. This highlights the importance of sun protection measures from an early age to prevent skin cancer.

Choice D reason: Basal cell carcinoma is the most common and least aggressive type of skin cancer. It rarely metastasizes and is usually slow-growing, making early detection and treatment highly effective.