A. Asking “Why do you think you are being lied about and poisoned?” encourages the client to elaborate on a delusion, which can reinforce the false belief rather than help the client gain insight. This response is not therapeutic.
B. Asking “Who is lying about you and trying to poison you?” validates the delusion by treating it as reality, which is not appropriate in managing psychotic symptoms.
C. Saying “You are mistaken. Nobody is lying about you or trying to poison you.” directly contradicts the client’s delusion. This approach can increase defensiveness and damage trust in the nurse-client relationship.
D. “You seem to be having very frightening thoughts.” is the correct response because it acknowledges the client’s emotional experience without validating or challenging the delusion. This promotes therapeutic communication by expressing empathy and encouraging the client to explore feelings in a supportive way.

A. Babinski’s sign is assessed by stroking the sole of the foot to observe toe movement, often used to evaluate neurological function in infants or identify central nervous system damage in adults. It is not related to the client’s current symptoms of tingling or recent thyroid surgery.
B. Kernig’s sign is used to detect meningeal irritation (as in meningitis) and involves resistance and pain on extending the knee while the hip is flexed. It is unrelated to postoperative thyroidectomy care.
C. Chvostek’s sign is the correct assessment. It involves tapping the facial nerve just in front of the ear to observe for twitching of facial muscles, indicating hypocalcemia. Tingling around the mouth and in the hands and feet are classic signs of low calcium levels, a possible complication after thyroid surgery due to accidental removal or damage to the parathyroid glands.
D. Brudzinski’s sign is another test for meningeal irritation, elicited by flexing the neck and observing involuntary flexion of the hips and knees. It is not relevant in this postoperative scenario.

A. Malignant hypertension is a hypertensive emergency characterized by extremely high blood pressure with end-organ damage. It is not typically associated with diabetic ketoacidosis (DKA), which more commonly presents with hypotension due to dehydration.
B. Acetone odor to breath is a hallmark sign of DKA. It results from the buildup of ketones (especially acetone) in the blood due to the breakdown of fat for energy when insulin is insufficient. This gives the breath a characteristic fruity or nail-polish-like odor.
C. Cheyne-Stokes breathing is a pattern of periodic breathing often seen in neurologic or end-of-life conditions, not typically associated with DKA. In DKA, Kussmaul respirations—deep and rapid breathing—are more characteristic as the body attempts to compensate for metabolic acidosis.
D. Blood glucose level below 40 mg/dL indicates severe hypoglycemia, which is the opposite of DKA. DKA typically presents with hyperglycemia, usually with blood glucose levels above 250 mg/dL.

A. “I will need to wipe my perineal area from back to front after urination” indicates a need for further teaching. Wiping from back to front increases the risk of introducing bacteria from the anal area into the urethra, which can lead to a urinary tract infection. The correct method is to wipe from front to back.
B. “I will need to drink apple cider vinegar each day” is a common home remedy belief. While scientific evidence is limited, apple cider vinegar is thought by some to help maintain urinary tract health due to its potential antibacterial properties. This statement does not necessarily indicate a misunderstanding.
C. “I need to drink 8 cups of liquid each day” is correct. Adequate fluid intake helps flush bacteria from the urinary tract and reduces the risk of infection.
D. “I will need to empty my bladder regularly and completely” is correct. Incomplete bladder emptying or infrequent urination can promote bacterial growth, so regular and full voiding helps prevent UTIs.

A. Creatinine decreasing is incorrect. In chronic kidney disease (CKD), serum creatinine levels increase as kidney function declines and the kidneys are less able to excrete waste products.
B. Glomerular filtration rate (GFR) increasing is incorrect. As CKD progresses, GFR decreases, reflecting reduced kidney filtering capacity. An increasing GFR would indicate improving kidney function, which is not typical in progressive CKD.
C. Proteinuria decreasing is incorrect. In CKD, proteinuria (protein in the urine) usually increases due to damage to the glomeruli, allowing proteins like albumin to pass through the filtration barrier into the urine.
D. Urine albumin increasing is correct. As kidney function worsens, the glomeruli become more permeable, leading to increased albumin in the urine, known as albuminuria or proteinuria. This is a key marker of kidney damage and progression of CKD.

A. Spending time sitting with the client is the correct and most therapeutic approach. Clients with severe depression often feel isolated and may have difficulty engaging in conversation or activities. Simply sitting quietly with the client shows presence, support, and acceptance, which can help build trust and provide comfort without placing pressure on the client to interact.
B. Encouraging decision-making may be inappropriate in the early stages of severe depression, as the client might feel overwhelmed or incapable of making even simple decisions due to impaired concentration and low motivation.
C. Playing a game of chess with the client may be too cognitively demanding and potentially frustrating for a client in a severely depressed state. It is better reserved for when the client is showing signs of improvement.
D. Giving the client choices of activities might seem supportive, but offering too many choices can increase anxiety and indecisiveness in someone who is severely depressed. Early in treatment, it's more helpful to offer structured support rather than open-ended decisions.

A. Administering corticosteroid medications is incorrect. In Cushing's syndrome, the body already has excess cortisol, either due to endogenous overproduction or prolonged corticosteroid use. The priority is to reduce cortisol levels, not increase them.
B. Assessing for signs of infection is correct. Excess cortisol suppresses the immune system, making patients with Cushing's syndrome highly susceptible to infections. These infections may not present with typical signs (e.g., fever) due to immune suppression, so vigilant assessment is a priority to prevent complications.
C. Providing emotional support is important, as patients may experience body image issues and mood changes, but it is not the immediate priority when life-threatening complications like infection are possible.
D. Monitoring blood glucose levels is also important, since hyperglycemia is common due to cortisol’s effects on glucose metabolism. However, infection risk poses a more immediate threat to patient safety, making infection assessment the top priority.

A. “If you take too many showers...” is incorrect. Showering does not significantly increase UTI risk. In fact, proper hygiene can help prevent UTIs. Overwashing or using harsh soaps may cause irritation, but regular showers are not a primary cause.
B. “At your age, you have more sexual intercourse...” is a generalization and not necessarily accurate. While sexual activity can increase UTI risk, the statement makes an assumption based on age rather than addressing anatomy or physiology.
C. “As a female, you have a shorter urethra creating an easier way for bacteria to invade your bladder” is correct. Women have a shorter urethra than men, and it is located closer to the anus, which makes it easier for bacteria (especially E. coli) to enter the bladder, increasing the risk of UTIs.
D. “As a female, you have more E. coli in your gastrointestinal system...” is incorrect. Both males and females have similar GI flora, including E. coli. The difference lies in anatomical proximity and urethral length, not in the amount of bacteria.

A. 0815 is incorrect. If breakfast is delayed too long after administering regular insulin, the client could experience hypoglycemia because regular insulin peaks in about 2 to 3 hours, and there would be no food to balance its effect.
B. 0720 is too soon. Administering breakfast just 5 minutes after insulin is given could cause a mismatch in insulin action and food intake, potentially leading to hypoglycemia.
C. 0745 is also incorrect. Giving breakfast 30 minutes after administering insulin is still too close, as the insulin may be acting too strongly before the food intake.
D. 0730 is correct. Regular insulin typically peaks around 2-3 hours after administration, so providing breakfast at 0730 (15 minutes after the insulin) allows for appropriate timing between insulin onset and food consumption, reducing the risk of hypoglycemia.

A. Dextrose 5% in 0.45% sodium chloride is incorrect. Dextrose is not typically given in the initial management of diabetic ketoacidosis (DKA) because it can elevate blood glucose levels further. The primary goal in treating DKA is to lower the blood glucose level and correct the acidosis, not to add glucose to the system at this stage.
B. Oral hypoglycemic medications are not appropriate in DKA. The client is in a state of severe hyperglycemia and acidosis, and oral medications are ineffective for rapid glucose control in this emergency. Insulin is the treatment of choice.
C. Glucocorticoid medications are not indicated in DKA treatment. Glucocorticoids could actually worsen hyperglycemia, and they are not used to treat DKA.
D. 0.9% sodium chloride IV bolus is correct. In DKA, dehydration is common due to osmotic diuresis, and the priority treatment is to restore fluid balance. An IV bolus of normal saline (0.9% sodium chloride) is the first step to rehydrate the client and improve circulation. Once hydration begins, insulin therapy is typically initiated to reduce blood glucose and address the acidosis.