Section: Questions Set G
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/Reference:
Explanation:
(A) Constipation is a result of decreased peristalsis due to smooth muscle relaxation related to changing progesterone levels that occur during pregnancy. (B) Urinary frequency is a common result of the increasing size of the uterus and the resulting pressure it places on the bladder. (C) With the increased vascularity and hypertrophy of the mammary alveoli due to estrogen and progesterone level changes, the breasts will increase in size and may become tender. (D) Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption.

(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.

Explanation
(A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening situation.

Section: Questions Set G
Explanation:
(A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock.