A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?

Correct Answer: C

Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.

Correct Answer: B

Rationale: Encouraging increased fluid intake is the most appropriate intervention to promote airway clearance in a client with pneumonia. Adequate hydration helps to thin respiratory secretions, making it easier for the client to cough up and clear the airways. Administering bronchodilators (Choice A) may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy (Choice C) can be beneficial in certain cases but may not be the initial intervention for promoting airway clearance. Providing humidified oxygen (Choice D) can help improve oxygenation but does not specifically target airway clearance in pneumonia.

Correct Answer: D

Rationale: The correct answer is D, Asterixis. Asterixis, also known as liver flap, is a sign of hepatic encephalopathy, a severe complication of liver disease that necessitates immediate attention. While jaundice (choice A), ascites (choice B), and spider angiomas (choice C) are common clinical findings in cirrhosis, asterixis is the most concerning due to its association with hepatic encephalopathy, which can lead to altered mental status and even coma. Jaundice, ascites, and spider angiomas are also important signs in cirrhosis, but asterixis indicates a more critical condition requiring urgent intervention.

Correct Answer: B

Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.

Correct Answer: D

Rationale: A comprehensive care plan for a client with depression should include multiple components to address various aspects of health. Regular physical activity can help improve mood and overall well-being. Scheduled sleep patterns are essential as sleep disturbances are common in depression and can worsen symptoms. Social interaction with family and friends provides emotional support and reduces feelings of isolation. Therefore, including all these aspects in the care plan can help support the client's recovery. Choice D, 'All of the above,' is the correct answer because all the options are important components of a holistic care plan for depression. Choices A, B, and C are incorrect because each of these elements plays a crucial role in managing depression.