Correct Answer: D

Rationale: You should not tell the client you are counting their respirations, as this may cause them to alter their breathing pattern. Pretending to check a pulse allows you to get close to the client without cluing them in to what you are assessing. Standing across the room is not the best way to assess for respirations as they may be difficult to see.

Correct Answer: B

Rationale: By 6 months, children should be able to recognize familiar faces, and thus they are aware of strangers. Strangers may illicit anxiety.

Correct Answer: A

Rationale: The nurse should not speak in a loud voice just because the client is elderly. The nurse should assess the client for a hearing impairment to see if additional assistance is required. However, elderly clients tend to require more time to process information, since their reaction time is slower, and they may benefit from more frequent, shorter sessions as they fatigue easily. Elderly clients are usually capable of absorbing supplemental written resources.

Correct Answer: B

Rationale: The vastus lateralis muscle, highlighted by the letter B, should be used in infants as the muscle tends to be thickest in this area.

Correct Answer: B

Rationale: The client's statement about medication diligence shows that this client could be compliant with a daily oral contraceptive. Contraindications to oral contraception include breast cancer, a history of deep vein thrombosis, and smoking if over age 35.