A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?

Correct Answer: D

Rationale: The correct answer is D: Teach them to limit sugar and caffeine intake. Rationale: 1. Sugar and caffeine intake can exacerbate anxiety and interfere with sleep due to their stimulant effects. 2. Limiting these substances can help regulate the body's energy levels and reduce anxiety symptoms. 3. By teaching the client to limit sugar and caffeine intake, the nurse is addressing the root causes of the client's sleeplessness and anxiety. Summary: A: Encouraging daily rituals may provide structure but does not directly address the physiological effects of sugar and caffeine on anxiety. B: Reinforcing the reality of the financial situation may increase anxiety rather than alleviate it. C: Drinking red wine at bedtime is not a recommended solution for managing anxiety and sleeplessness.

Correct Answer: B

Rationale: The correct answer is B: "The medication will help you think more clearly." This is the most appropriate statement to educate the client about clozapine. Clozapine is an antipsychotic medication used to treat schizophrenia and helps with cognitive symptoms such as disorganized thinking. Choice A is too vague and doesn't specify the medication's intended effect. Choice C is too general and doesn't focus on cognitive improvement. Choice D is incorrect as clozapine does not specifically target grooming and hygiene but rather cognitive symptoms.

Correct Answer: D

Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.

Correct Answer: D

Rationale: The correct answer is D: Beractant (Survanta) 100 mg/kg per endotracheal tube. In this scenario, the infant's high respiratory rate indicates respiratory distress, likely due to immature lungs. Beractant is a pulmonary surfactant used to treat respiratory distress syndrome in preterm infants by improving lung function and reducing the risk of complications. Administering beractant via endotracheal tube helps deliver the medication directly to the lungs. Choice A (Ampicillin) is an antibiotic used for treating infections, not respiratory distress. Choice B (Gentamicin) is an antibiotic for infections, not respiratory distress. Choice C (Digoxin) is a cardiac medication for heart conditions, not respiratory distress. Therefore, only choice D addresses the respiratory distress issue in the preterm infant, making it the most appropriate drug for the transport team to administer in this case.

Correct Answer: A

Rationale: The correct answer is A because the OB nurse's background in obstetrics makes them most suitable to care for a post-operative patient with an IV. This assignment aligns with the nurse's skill set and ensures safe and competent care. Choices B, C, and D involve medical-surgical conditions that may require specialized knowledge and skills beyond the OB nurse's expertise, potentially compromising patient care. Assigning the OB nurse to care for a post-operative patient with an IV is the most appropriate choice given the circumstances.