The nurse is preparing a teaching plan for a client diagnosed with asthma. The primary purpose of the plan is to

Correct Answer: D

Rationale: In preparing a teaching plan for a client diagnosed with asthma, the primary purpose is to educate them on avoiding allergens that trigger attacks, which is the correct answer (D). This is crucial as allergens such as dust mites, pollen, and pet dander can exacerbate asthma symptoms and lead to potentially life-threatening attacks. By identifying and avoiding these triggers, the client can effectively manage their condition and reduce the frequency and severity of asthma attacks. Option A (Prevent respiratory infections) is not the primary purpose of an asthma teaching plan, although preventing infections is important for overall health, it is not directly related to managing asthma. Option B (Prevent airway inflammation) is also essential in asthma management, but the primary focus of a teaching plan is to educate the client on trigger avoidance and symptom management. Option C (Maintain an open airway) is a general goal of asthma management but does not address the specific aspect of trigger avoidance, which is the primary focus of the teaching plan. In an educational context, understanding the rationale behind the correct answer helps nurses tailor their teaching plans to meet the specific needs of clients with asthma. By emphasizing trigger avoidance and symptom management, nurses can empower clients to take an active role in managing their condition and improving their quality of life. A thorough understanding of asthma triggers and effective communication of this information is key to successful asthma management.

Correct Answer: B

Rationale: In the context of a client who is bedridden after a stroke, the most important nursing intervention in preventing pressure ulcers is to reposition the client every 2 hours (Option B). This is crucial as frequent repositioning helps to relieve pressure on bony prominences, improves circulation, and reduces the risk of tissue ischemia and subsequent ulcer formation. Applying lotion every 4 hours (Option A) may help with skin hydration but does not address the root cause of pressure ulcer development. Elevating the head of the bed 30 degrees (Option C) is important for preventing aspiration in some cases but does not directly prevent pressure ulcers. Massaging the skin at least twice a day (Option D) can actually exacerbate the risk of pressure ulcers by increasing friction and shearing forces on the skin. In an educational context, understanding the rationale behind the correct intervention reinforces the importance of evidence-based practice in nursing care. It highlights the significance of proactive measures to prevent complications such as pressure ulcers, emphasizing the role of nursing interventions in maintaining patient skin integrity and overall well-being.

Correct Answer: C

Rationale: In this scenario, the correct response (option C) demonstrates empathy and a focus on problem-solving. By acknowledging the UAP's feelings and suggesting a collaborative approach to address the challenging situation, the nurse validates the UAP's emotions and fosters a supportive environment. This response promotes open communication, teamwork, and a patient-centered approach to care. Option A is incorrect because it dismisses the UAP's feelings and places the blame on the client, lacking empathy and problem-solving. Option B is not ideal as it puts the responsibility solely on the nurse to resolve the issue, missing the opportunity to involve the UAP in finding a solution collaboratively. Option D is inappropriate as it ignores the UAP's emotional distress and suggests avoiding the problem, which does not address the underlying issue or support the UAP effectively. Educationally, this scenario highlights the importance of effective communication, teamwork, and empathy in healthcare settings. It emphasizes the need for nurses to support and empower their colleagues, fostering a positive work environment and enhancing patient care outcomes through collaborative problem-solving.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Obtain more details of the client's claim of abuse. This is the most appropriate initial action because it prioritizes the client's safety and well-being. By gathering more information about the alleged abuse, the nurse can assess the situation comprehensively before taking further steps. Option A, focusing on reality orientation, is not the most immediate concern when a client discloses abuse. While it is important in certain situations, addressing the abuse claim takes precedence. Option B, assisting with the report to the police, should come after verifying the client's claim to ensure accuracy and appropriateness of involving law enforcement. Option D, documenting the statement on the client's chart, is important but should follow a thorough assessment and investigation of the abuse allegation to ensure proper documentation. Educationally, this question highlights the critical thinking skills needed in nursing practice when faced with sensitive and potentially harmful situations. It emphasizes the importance of assessing and investigating before taking action to ensure the best possible outcome for the client.

Correct Answer: B

Rationale: The correct answer is B) Moderate impairment. The Glasgow Coma Scale (GCS) is a neurological scale that assesses a patient's level of consciousness following a brain injury. A GCS score of 10 indicates a moderate impairment in the client's level of consciousness. Option A) Mild impairment is incorrect because a GCS score of 13-15 is considered mild impairment, not 10. Option C) Severe impairment is also incorrect as GCS scores indicating severe impairment typically fall below 8. Option D) Normal is incorrect because a GCS score of 10 does not indicate a normal level of consciousness. In an educational context, understanding the GCS scoring system is crucial for healthcare professionals, especially in emergency situations like motor vehicle accidents. It helps in quickly assessing and communicating a patient's neurological status, guiding treatment decisions and predicting outcomes. Healthcare providers must accurately interpret GCS scores to provide appropriate care and interventions based on the level of impairment indicated.