Section: Questions Set B
Explanation:
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs
14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22).

Explanation
(A) Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.

Explanation
(A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye.
(C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility.

Explanation
(A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.

(A) Objects from home do not reduce fear of the unknown. Children need explanations, reassurance, and preparation for the unknown. Also, parental presence can promote comfort and feelings of security. (B) A calm, relaxed, and reassuring manner will assist in calming the child. The child's objects from home will not assist in calming the child. (C) A trusting relationship is based on the quality of the nurse-client relationship. Objects from home have no impact. (D) Favorite objects from home assist in creating a familiar setting. Also, these objects may prevent or minimize separation from the child's usual routine and family support.