A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Place the client on bed rest in a semi-Fowler's position.

Instruct the client to limit fluid intake to less than 2.000 mL/day.

Prepare to administer antibiotics.

Repeat auscultation after asking the client to breathe deeply and cough

Answer and Explanation

The Correct Answer is D

A- Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data

B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.

C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.

D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs

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Correct Answer is B

Explanation

Explanation: This statement is highly inappropriate and victim-blaming. It implies that the client's clothing choices are somehow responsible for the sexual assault they experienced. Victim-blaming is never acceptable and can be harmful to the survivor, making them feel ashamed and responsible for the actions of the perpetrator. As healthcare professionals, nurses should always respond to victims of sexual assault with empathy, compassion, and without judgment.

The other statements (A, C, and D) are all appropriate and acknowledge the seriousness of the situation:

A. "We need to offer the client emotional support especially when obtaining specimens." Explanation: This statement recognizes the need for emotional support during the examination process, which can be distressing for the survivor. Providing emotional support and ensuring the client's comfort and consent during the examination are crucial aspects of caring for a sexual assault survivor.

C. "The client feels like they won't be believed since there was alcohol involved during the date." Explanation: This statement highlights the survivor's feelings and concerns about being believed due to alcohol involvement. It emphasizes the importance of creating a safe and non-judgmental environment for the client, where they can share their experience and receive appropriate care and support.

D. "When the client said 'stop,' that was enough for the perpetrator to get up and walk away." Explanation: This statement indicates an understanding of the importance of consent and acknowledges that the client's clear expression of refusal should have been respected. Understanding and respecting consent is crucial when discussing cases of sexual assault.

A. A driver whose spouse and children all died as a result of his driving drunk B. An adult who insisted for many years that the adult hated the adult's deceased parent C. The parent of a child who died after having left the child in a car on a hot day D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day E. The spouse of a person who died 7 years ago and visits the grave several times a day

Correct Answer is ["B","C","D"]

Explanation

Complicated grieving, also known as complicated grief or prolonged grief disorder, refers to a type of grief that is prolonged, intense and does not follow the typical trajectory of mourning. It can manifest differently in different individuals, but some common signs of complicated grieving include:

B. An adult who insisted for many years that the adult hated the adult's deceased parent: This could indicate unresolved emotional conflicts with the deceased parent, which may be contributing to complicated grief.

C. The parent of a child who died after having left the child in a car on a hot day: This situation involves feelings of guilt and responsibility, which can complicate the grieving process.

D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day: This response is likely a normal grief response, as the person visits the grave once a year during Memorial Day, which is a common time for remembering and honoring deceased loved ones.

The following options are not necessarily indicative of complicated grieving:

A. A driver whose spouse and children all died as a result of his driving drunk: While this is undoubtedly a traumatic event, the description provided does not necessarily indicate complicated grieving specifically.

E. The spouse of a person who died 7 years ago and visits the grave several times a day: Visiting the grave several times a day might indicate a deep sense of loss, but it is not specific to complicated grieving and can vary depending on cultural practices and individual coping mechanisms.

It's essential to recognize that grief is a complex and individual process, and professional assessment and support are often required to identify and address complicated grieving in a person.

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A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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