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Question 1 of 5

A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?

Correct Answer: D

Rationale: Reinforcing boundaries (
D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (
A), assigning the preferred nurse (
B), or reassuring competence (
C) may reinforce manipulation.

Question 2 of 5

A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

Correct Answer: A

Rationale: In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.

Question 3 of 5

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.

Correct Answer: A, B, D

Rationale: Avoiding rubbing (
A), straining (
B), and reporting sudden pain (
D) prevent complications. Flashes (
C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.

Question 4 of 5

The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?

Correct Answer: C

Rationale: A 4-year-old with suspected meningitis requires urgent treatment. Notifying administration (
C) ensures legal and ethical intervention to protect the child. AMA (
A), power of attorney (
B), or respecting autonomy (
D) are inappropriate for a minor.

Question 5 of 5

The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply.

Correct Answer: A, B, D

Rationale: Taking with food (
A) reduces GI upset, completing the course (
B) prevents resistance, and shaking well (
D) ensures proper dosing. Rash (
C) is not normal and requires evaluation, and household spoons (E) are inaccurate.

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A client receiving aminophylline IV complains of feeling nervous and shaky. The nurse is aware that these are symptoms of:

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