Explanation/Reference:
Explanation:
(A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility.
(B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against.

(A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn. (C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure.

Explanation/Reference:
Explanation:
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.

Section: Questions Set B
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.

Section: Questions Set F
Explanation:
(A) Hiccups are not a sign of impending hepatic coma. (B) Anorexia is not a sign of impending hepatic coma.
(C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen. (D) This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may sometimes be noted when the liver fails.