Nokea
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. The rationale is as follows: The patient is at risk for developing hypertension based on his age, ethnicity, and BP reading. Providing information on reducing risk factors such as maintaining a healthy diet, regular exercise, stress management, and avoiding tobacco and excess alcohol can help prevent the development of hypertension. This proactive approach aligns with preventive healthcare measures.
Choices A, C, and D are incorrect because scheduling the next appointment for 1 year from now does not address the potential risk of hypertension, a PSA test is unrelated to the patient's current presentation, and weight loss is not indicated as the patient's BMI is within the normal range.
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A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?
- A. Use medical aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply petroleum jelly to the peristomal skin.
Correct Answer: C
Rationale: Securing new tracheostomy ties before removing old ones prevents accidental displacement. Medical asepsis is insufficient; sterile technique is required.
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
- A. Explain to the client what is about to happen.
- B. Make sure the room temperature is cool.
- C. Provide music as an environmental distraction.
- D. Inform the client that the provider will examine sensitive areas first.
Correct Answer: A
Rationale: The correct answer is A: Explain to the client what is about to happen. This is important to ensure the client's understanding and cooperation during the physical examination. By explaining the procedure, the nurse can reduce the client's anxiety and build trust. This communication also promotes client autonomy and respects their dignity. As for the other choices: B (Make sure the room temperature is cool) is not directly related to preparing the client for the physical examination. C (Provide music as an environmental distraction) may not be appropriate for all clients and may not address the client's emotional needs. D (Inform the client that the provider will examine sensitive areas first) may cause unnecessary anxiety without providing a clear understanding of the examination process.
A nurse is caring for a client who has hypertension and is afraid to take medication. Which of the following nursing responses uses reflection?
- A. You seem upset about your blood pressure.'
- B. What time do you take your medication?'
- C. How do you feel when you take the medication?'
- D. I understand your reluctance to use medication.'
Correct Answer: A
Rationale: Reflection restates the client's emotions, encouraging further discussion.
A nurse is collecting data as part of a neurological examination of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve?
- A. Instruct the client to look up and down without moving his head.
- B. Observe the client's ability to smile and frown.
- C. Evaluate the client's pupillary reaction to light.
- D. Ask the client to shrug his shoulders against passive resistance.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's pupillary reaction to light. The third cranial nerve, also known as the oculomotor nerve, controls the pupillary response by constricting the pupil when exposed to light. By observing the client's pupillary reaction to light, the nurse can assess the function of the third cranial nerve. This test specifically targets the parasympathetic fibers of the nerve, which control pupillary constriction.
Choice A (Instruct the client to look up and down without moving his head) would assess the function of the fourth cranial nerve (trochlear nerve).
Choice B (Observe the client's ability to smile and frown) would assess the function of the seventh cranial nerve (facial nerve).
Choice D (Ask the client to shrug his shoulders against passive resistance) would assess the function of the eleventh cranial nerve (accessory nerve).
Therefore, choices A, B, and D are
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.