Correct Answer: B

Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management.


Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal.
Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause.
Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.

Correct Answer: D

Rationale: Group therapy is a valuable approach in mental health treatment. Working with psychiatric clients in a group setting offers various benefits. Clients in a group setting can learn from others when their behaviors are inappropriate in a safe and trusting environment. This environment allows individuals to express thoughts and feelings without fear of judgment or criticism, fostering a supportive atmosphere. Through interactions with peers, clients can gain insight into their own behaviors and learn alternative ways of coping.
Choice A is incorrect as the presence and support of a nurse are typically important in group therapy sessions.
Choice B is incorrect as group settings provide structure and rules to ensure a safe space for clients to express themselves.
Choice C is incorrect as maintaining confidentiality is crucial in group therapy to build trust and encourage open sharing.

Correct Answer: A

Rationale: The correct answer is 'Nursing will help contract the uterus and reduce your risk of bleeding.' Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.
Choice B is incorrect because breastfeeding can actually help prevent further bleeding by promoting uterine contractions.
Choice C is incorrect as the blood transfusion is aimed at restoring the client's blood volume and should not significantly impact the babies.
Choice D is incorrect as lactation should not be delayed, as breastfeeding can provide numerous benefits to both the mother and infants, including aiding in the prevention of postpartum hemorrhage.

Correct Answer: A

Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options B and C are incorrect as they involve using the expired solution. Option A is incorrect as reusing the solution after it has been opened for more than 24 hours poses a risk of contamination.
Therefore, the best course of action is to discard the expired solution and obtain a new unopened bottle for sterile wound care.

Correct Answer: C

Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.