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A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?
- A. Encourage the client to ambulate more often.
- B. Encourage coughing and deep breathing.
- C. Encourage the client to drink more fluids.
- D. Encourage regular use of the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to drink more fluids. Increased fluid intake helps to thin respiratory secretions, making it easier for the client to cough them up and clear the airways. This action promotes effective airway clearance and reduces the risk of complications such as pneumonia worsening. Encouraging ambulation (A) is beneficial for overall lung health but does not directly address thinning of respiratory secretions. While coughing and deep breathing (B) are important for clearing secretions, increasing fluids is more effective in thinning them. Using the incentive spirometer (D) helps with lung expansion but does not directly thin secretions.
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A nurse is providing discharge teaching to a client following a right mastectomy. Which of the following statements should indicate to the nurse that the client has a healthy body image?
- A. Do I have to go home with drains?
- B. The incision looks like it is healing.
- C. My sister will change the dressing every day.
- D. When will all this pain start to go away?
Correct Answer: B
Rationale: A statement acknowledging the healing process suggests the client is adjusting positively to body image changes.
A nurse is planning to collect data about the abdomen of a client who reports 'stomach pain.' Which of the following actions should the nurse take first?
- A. Auscultate.
- B. Percuss.
- C. Inspect.
- D. Palpate.
Correct Answer: C
Rationale: Inspection is always the first step in an abdominal assessment to observe for any abnormalities before auscultation and palpation.
A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?
- A. Determine the client's perception of his body image.
- B. Encourage the client to talk about his feelings regarding his body image.
- C. Discuss alternative coping strategies to relieve stress he feels about his body image.
- D. Assist the client to acknowledge he has a distorted body image.
Correct Answer: A
Rationale: Assessing the client's perception of their body image is the first step in understanding their emotional and psychological response.
A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.
A nurse is admitting a client who has a partial hearing impairment. Which of the following actions is the nurse's priority?
- A. Speak using a normal tone of voice.
- B. Stand directly in front of the client.
- C. Rephrase statements as needed.
- D. Determine if the client uses a hearing aid.
Correct Answer: D
Rationale: Determining if the client uses a hearing aid is a priority because it can significantly impact communication and care planning.