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Questions 158

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Question 1 of 5

When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

Correct Answer: B

Rationale: When dealing with grief, siblings are usually most comfortable initially with open discussion. Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. This method may be helpful, but having the child take an active part through role playing is more effective. This technique may be helpful, but being an active participant through role playing is more effective.

Question 2 of 5

Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?

Order the Items

Source Container

Circle the surgical site with a marker.
Verify patient information with a designated patient representative.
Designate operative site with a facility designated mark.
Include a copy of the Advanced Directives on the chart before surgery.
Verify patient information three times.
Observe pre-op time out before proceeding with surgery.

Correct Answer: C, E, F

Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.

Question 3 of 5

The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?

Correct Answer: A

Rationale: Postpartum depression requires mental health intervention such as referral to a psychiatrist for therapy or medication. Antibiotics fetal monitoring and tocolytics are irrelevant to this condition.

Question 4 of 5

The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:

Correct Answer: A

Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.

Question 5 of 5

An appropriate nursing intervention for the client with borderline personality disorder is:

Correct Answer: A

Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.

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