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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 reinforcing teaching with an older adult client. Which of the following strategies should the nurse use?
- A. Incorporate teaching needs into one daily session.
- B. Emphasize visual and auditory teaching techniques.
- C. Minimize distractions by closing the door to the room.
- D. Begin with the most difficult learning tasks.
Correct Answer: B
Rationale: The correct answer is B: Emphasize visual and auditory teaching techniques. Older adults may have sensory impairments, so utilizing visual and auditory cues can enhance learning. Visual aids like charts and diagrams, along with verbal explanations, can cater to different learning styles. This approach promotes better retention and understanding.
Incorrect options: A: Incorporating teaching needs into one daily session may overwhelm the older adult. C: Closing the door may create a sense of isolation. D: Beginning with the most difficult tasks can be discouraging and hinder learning progress.
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
- A. It delivers a specific concentration of oxygen constantly.
- B. It delivers the highest concentration of oxygen possible.
- C. It delivers the low concentration of oxygen you need.
- D. It allows you to remove it for a while when it gets uncomfortable.
Correct Answer: C
Rationale: The correct answer is C: It delivers the low concentration of oxygen you need. Nasal cannulas deliver a low flow rate of oxygen, typically between 1-6 liters per minute, providing a lower concentration of oxygen compared to other oxygen delivery devices. This is suitable for clients who require only a slight increase in their oxygen levels. Choice A is incorrect as nasal cannulas do not deliver a specific concentration of oxygen constantly. Choice B is incorrect as nasal cannulas do not deliver the highest concentration of oxygen possible. Choice D is incorrect because nasal cannulas should not be removed when uncomfortable as it disrupts the oxygen therapy.
A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect?
- A. Ability to perform oral hygiene
- B. Ability to bathe himself
- C. Ability to identify how often he should schedule his car for an oil change
- D. Ability to balance his bank account
- E. Ability to dress himself
Correct Answer: A,B,E
Rationale: Assessing ADLs includes evaluating self-care abilities like hygiene, bathing, and dressing.
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?
- A. When the client has the urge to defecate
- B. Every 2 hr while the patient is awake
- C. Immediately before meals
- D. After the client feels abdominal cramping
Correct Answer: A
Rationale: The correct answer is A: When the client has the urge to defecate. This is crucial for a successful bowel training program because it helps the client establish a regular bowel routine and strengthens the mind-body connection for recognizing the urge to defecate. Taking the client to the bathroom when they feel the urge also promotes independence and empowers the client to listen to their body's signals.
Choice B (Every 2 hr while the patient is awake) is incorrect because it does not align with the principles of bowel training, which focuses on responding to the body's natural signals. Choice C (Immediately before meals) is incorrect as the timing is not based on the client's physiological cues. Choice D (After the client feels abdominal cramping) is incorrect because waiting for abdominal cramping can lead to discomfort and is not proactive in managing bowel movements.
A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). Which of the following should the nurse instruct the client to avoid for at least 3 days before the test?
- A. Whole grain cereal
- B. Magnesium hydroxide
- C. Orange juice
- D. Acetaminophen
Correct Answer: B
Rationale: The correct answer is B: Magnesium hydroxide. This is because magnesium hydroxide, commonly found in antacids and laxatives, can cause false-positive results in a fecal occult blood test (FOBT) due to its chemical reaction with the test reagents. Instructing the client to avoid magnesium hydroxide for at least 3 days before the test ensures accurate results.
Incorrect choices:
A: Whole grain cereal - Whole grain cereal does not interfere with FOBT results.
C: Orange juice - Orange juice does not impact FOBT results.
D: Acetaminophen - Acetaminophen does not affect FOBT results.
Therefore, avoiding magnesium hydroxide is crucial to obtaining reliable results in the FOBT.