Explanation
(A) Raising the client's head and placing her feet in a dependent
position is an independent nursing action that can be taken to
decrease venous return and to reduce pulmonary congestion. (B)
Notifying the physician is an appropriate action that should be
taken after the client is positioned to maximize her respiratory
status. (C) Placing the client on O2may be done with a physician's
order or according to an institution's standing orders; however,
other actions should be taken first. (D) Furosemide 20 mg
IV push is an appropriate medication for the client, but it must
be ordered by her physician.

(A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapist's behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.

Explanation
(A) Weighing a child with nephrosis is to assess for edema, not nutrition. (B, C) This is not the purpose for weighing the child. (D) Weight and measurement are the primary ways of evaluating edema and fluid shifts.

Explanation
(A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.

Explanation
(A) The immediate action is to neutralize the action of the chemical before further damage takes place. (B) This action should be done after neutralizing the chemical. (C) This action should be done after neutralizing the chemical. (D) Never induce vomiting with a strong alkali or acid. Additional damage will be done when the child vomits the chemical.