Nokea
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?
- A. Hypertension.
- B. Diabetes mellitus.
- C. Inadequate lifestyle changes in diet and exercise.
- D. Increased risk of chronic illnesses.
Correct Answer: C
Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.
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When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?
- A. Leave a detailed message about the client's condition.
- B. Tell the receptionist to have the healthcare provider return the phone call.
- C. Call another healthcare provider.
- D. Document the attempt to call the healthcare provider.
Correct Answer: B
Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.
The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?
- A. client's score on an alcohol screening instrument
- B. results of a urine drug and alcohol screen
- C. most recent community census data
- D. documentation of client education in the nursing record
Correct Answer: D
Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.
A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Blood pressure of 130/80 mm Hg.
- C. Respiratory rate of 20 breaths per minute.
- D. Chest pain radiating to the left arm.
Correct Answer: D
Rationale: The correct answer is D. Chest pain radiating to the left arm can be a sign of myocardial infarction (heart attack) and requires immediate intervention. This symptom is known as a classic presentation of a heart attack and warrants urgent medical attention to prevent further cardiac damage. Choices A, B, and C are not directly indicative of an acute cardiac event and may not require immediate intervention in this scenario. While heart rate, blood pressure, and respiratory rate are important vital signs to monitor, they do not specifically indicate the urgency associated with chest pain radiating to the left arm in a patient with a history of coronary artery disease.
The healthcare provider is developing a community outreach program to address childhood obesity. Which intervention should the healthcare provider implement first?
- A. conduct a survey to assess dietary habits and physical activity levels
- B. develop educational materials on healthy eating and exercise
- C. partner with local schools to promote physical activity programs
- D. organize community events that encourage healthy lifestyle choices
Correct Answer: A
Rationale: Conducting a survey to assess dietary habits and physical activity levels should be the initial step in developing a community outreach program to address childhood obesity. By gathering data through a survey, the healthcare provider can identify specific needs, preferences, and challenges within the community. This information is crucial for designing tailored interventions that are more likely to be effective. Developing educational materials (Choice B) can come after understanding the community's needs through the survey. Partnering with local schools (Choice C) and organizing community events (Choice D) are important strategies but should be planned based on the data obtained from the survey to ensure relevance and impact.
A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?
- A. Apply a petroleum-based lubricant to the lips.
- B. Give sips of water.
- C. Provide ice chips.
- D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.
Correct Answer: D
Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.