Explanation/Reference:
Explanation:
(A) The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. (B) The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. (C) Depressed persons often have little appetite and poor fluid intake. Constipation is common. (D) A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.

(A) Protein increases the workload of the liver. Increased carbohydrates provide needed calories and promote palatability. (B) Dietary intake should be adequate to ensure wound healing. (C) Increased carbohydrates provide needed calories. (D) A highcalorie diet is best obtained from carbohydrates because of their palatability. Fats increase the workload of the liver.

Explanation
(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches whenever possible before leakage occurs.
(D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.

Section: Questions Set A
Explanation:
(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.

Explanation/Reference:
Explanation:
(A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid volume excess.