The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?

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Question 1 of 5

The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?

Correct Answer: B

Rationale: Ineffective cough and sputum indicate airway clearance issues.

Question 2 of 5

A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

Correct Answer: B

Rationale: Assigning age-appropriate tasks fosters involvement and responsibility.

Question 3 of 5

A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying 'no' and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?

Correct Answer: C

Rationale: Negativism at this age reflects autonomy development (Erikson's stage).

Question 4 of 5

Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?

Correct Answer: B

Rationale: Identifying specific guilt and actionable steps promotes coping and recovery.

Question 5 of 5

A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize

Correct Answer: B

Rationale: Early thyroid hormone treatment prevents developmental delays.

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