The hospitalized client states, 'I need to know when I'm going to be discharged. I'm so upset and worried that I'm missing work.' The nurse knows this is an example of:

Correct Answer: B

Rationale: The correct answer is B: distress; could affect the client's health status. The client's statement reflects distress, a negative form of stress that can have adverse effects on health. The client's worry about missing work indicates potential negative consequences on their health status. It is important for the nurse to address this distress to prevent further negative impacts on the client's well-being. A: Eustress refers to positive stress and does not require intervention. C: Prescribing antidepressants based solely on the client's statement is not appropriate as this does not indicate a need for medication. D: Developmental stress is not the most appropriate term for the client's situation, and suggesting talking to someone his own age may not address the root cause of the distress.

Correct Answer: B

Rationale: The correct answer is B - Wait 1-5 minutes as prescribed. This is because for most inhalers, it is recommended to wait a specific amount of time between puffs to allow the medication to take effect and maximize its effectiveness. Waiting 1-5 minutes ensures proper absorption and distribution of the medication in the lungs. Administering immediately (choice A) may not allow the first puff to take full effect. Waiting 10 minutes (choice C) or 15 minutes (choice D) is too long and may not provide optimal therapeutic benefit. Therefore, waiting 1-5 minutes is the most appropriate choice.

Correct Answer: A

Rationale: Step 1: Swallowing elevates the thyroid gland, making it easier to palpate. Step 2: Swallowing also moves the thyroid gland closer to the skin surface. Step 3: This helps the nurse accurately assess the size, shape, and texture of the thyroid gland. Step 4: Holding breath, flexing, or hyperextending the neck does not provide optimal access for palpation. Summary: Swallowing is the correct choice as it enhances visibility and accessibility for thyroid gland palpation, while the other options do not provide the same benefits.

Correct Answer: A

Rationale: The correct answer is A: Polypharmacy. Polypharmacy refers to the concurrent use of multiple medications, which can lead to drug interactions and adverse effects, such as dizziness. In this case, the client is experiencing dizziness due to combining the herbal remedy with prescribed medications, highlighting the risks of polypharmacy. B: Sleep disorder is incorrect because dizziness is not typically a symptom of a sleep disorder. C: Cascade iatrogenesis is incorrect as it refers to a chain of events where one intervention leads to multiple adverse outcomes, which is not directly related to the client's dizziness in this scenario. D: Fluid volume overload is incorrect as it typically presents with symptoms like swelling, shortness of breath, and weight gain, rather than dizziness.

Correct Answer: D

Rationale: The correct answer is D: notify healthcare provider (HCP). This is the most appropriate action as hearing an extra sound could indicate a potential abnormality such as a crackle or wheeze. Notifying the HCP promptly allows for further assessment and appropriate intervention if needed. Choice A: Documenting the finding is important, but not the most immediate action when an abnormal sound is heard. Choice B: Asking the client to cough may not address the underlying cause of the extra sound and delay necessary intervention. Choice C: Reassessing in one hour could be too delayed for a potentially serious issue and may lead to worsening of the condition. Therefore, notifying the HCP is the best course of action for timely intervention and ensuring patient safety.