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A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
- A. Limit the client's social interactions.
- B. Encourage the client to be assertive.
- C. Assume responsibility for making the client's decisions.
- D. Maintain a verbal no-harm contract with the client.
Correct Answer: B
Rationale: Encouraging assertiveness promotes independence, countering dependency tendencies. Limiting interactions or making decisions for the client reinforces dependence, and no-harm contracts are unrelated.
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A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?
- A. I will take my inhaler treatment before each meal and at bedtime.
- B. I should use my inhaler before exercising.
- C. I should use my inhaler when I have an asthma attack.
- D. I will rinse my mouth and gargle with water after each inhaler treatment.
Correct Answer: D
Rationale: Rinsing the mouth after budesonide use prevents oral thrush, a key self-care step. Budesonide isn't timed with meals, used before exercise routinely, or for acute attacks.
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following actions should the nurse take?
- A. Position the client flat in bed.
- B. Monitor the client's neurological status every 2 hr.
- C. Encourage the client to cough vigorously.
- D. Administer a stool softener as needed.
Correct Answer: B
Rationale: Frequent neurological checks detect complications like increased intracranial pressure early. Flat positioning risks pressure, vigorous coughing is avoided, and stool softeners prevent straining.
A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports shoulder pain.
- B. The client's temperature is 38.2°C (100.8°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with slight redness.
Correct Answer: B
Rationale: A temperature of 38.2°C suggests infection, requiring reporting. Shoulder pain is referred pain, no bowel movement is expected, and slight redness is normal.
A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Understands that everyone dies eventually
- B. Recognizes the parent will never wake up
- C. Expresses curiosity about the funeral service
- D. Believes death is punishment for bad behavior
Correct Answer: D
Rationale: Preschoolers often believe death is a punishment due to magical thinking. Understanding permanence or universal death is beyond their developmental stage.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if a transfusion reaction is suspected?
- A. Increase the infusion rate.
- B. Administer diphenhydramine.
- C. Stop the transfusion.
- D. Elevate the client's legs.
Correct Answer: C
Rationale: Stopping the transfusion prevents further reaction. Increasing the rate worsens it, diphenhydramine is secondary, and leg elevation is unrelated.