Explanation
(A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent. Sibling would be asked last.

Explanation
(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.

Explanation
(A) This option provides adequate spacing of the medication and will limit the client's need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the client's usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls.

Explanation
(A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP.
Neither one should be expected, but the mother should know to notify the physician or hospital if they occur.
(C) The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

Section: Questions Set B
Explanation:
(A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (1ꢀ2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client's head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.