Nokea
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?
- A. Encourage the client to walk for 5 minutes each hour.
- B. Refer the client for smoking cessation classes.
- C. Teach the client about factor V Leiden testing.
- D. Explain to the client that sometimes no cause for the disease is found.
Correct Answer: C
Rationale: The correct answer is C because teaching the client about factor V Leiden testing is important in this scenario. Factor V Leiden is a genetic mutation that increases the risk of blood clot formation, including pulmonary embolism. Since the client has no known risk factors for PE, testing for this specific genetic mutation can help identify an underlying cause. Encouraging walking (choice A) is generally beneficial but may not address the root cause. Referring for smoking cessation (choice B) is not relevant in this case. Explaining that sometimes no cause is found (choice D) is not proactive and may lead to missed opportunities for prevention.
You may also like to solve these questions
A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.
A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
- A. I plan to wear my oxygen when I exercise & feel short of breath.
- B. I will use my portable oxygen when grilling burgers in the backyard.
- C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
- D. I will only smoke while I am wearing my oxygen via nasal cannula.
Correct Answer: C
Rationale: The correct answer is C because using cotton balls to cushion the oxygen tubing on the ears helps prevent skin irritation or pressure ulcers. This indicates the client understands the importance of skin care and comfort while using oxygen therapy.
A: Incorrect. The client should wear oxygen during all activities that increase oxygen demand, not just when feeling short of breath during exercise.
B: Incorrect. Using portable oxygen near an open flame like a grill can result in a fire hazard.
D: Incorrect. Smoking while using oxygen therapy is extremely dangerous and can lead to a fire.
Which setting allows the dying client to have advanced care in an institution due to the necessity to control pain unable to be managed at home?
- A. Hospice care
- B. Acute care
- C. Palliative care
- D. Home care
Correct Answer: C
Rationale: Palliative care specializes in managing complex symptoms and pain, providing advanced institutional support.
Why is empathetic listening important during nurse-client communication?
- A. It helps in building trust and understanding.
- B. It ensures compliance with medical advice.
- C. It facilitates reaching the goals of a client.
- D. It avoids overwhelming a client with new information.
Correct Answer: A
Rationale: Empathetic listening allows the nurse to understand the client's concerns deeply, which strengthens the therapeutic relationship and improves care outcomes.
A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.