An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

Correct Answer: C

Rationale: How many pillows do you use at night to sleep comfortably?' is most appropriate. Edema resolving at night suggests cardiac or venous issues; pillow use indicates orthopnea, per cardiovascular assessment. Heart attack , dyspnea , and smoking are less specific initially. C pinpoints severity.

Correct Answer: D

Rationale: Eliciting clients' descriptions of experiences, thoughts, and behaviors is optimal. It gathers subjective data comprehensively, per assessment standards. Nonverbal is part, structure limits depth, and free talk lacks focus. D ensures thorough, client-centered data.

Correct Answer: B

Rationale: Frequent turning is most important to prevent skin breakdown in elderly on bed rest. Repositioning relieves pressure, per gerontological nursing. Massage risks damage, lotions hydrate but don't prevent, and heat worsens redness. B is the primary intervention.

Correct Answer: C

Rationale: Ethnocentrism describes the nurse's response. Judging acupuncture as 'weird' and 'scary' reflects a bias toward Western norms, per cultural competence. Prejudice is broader, discrimination involves action, and insensitivity is less specific. C fits the attitude.

Correct Answer: A

Rationale: Applying suction for no more than 10 seconds prevents hypoxia during tracheostomy suctioning. Prolonged suction depletes oxygen, per airway management standards. Sterility , lubrication , and motion matter but hypoxia is the primary risk. A safeguards oxygenation.