Nokea
A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. The most appropriate action by the nurse is to do which of the following?
- A. Reassure the client that her children will be fine and she should stop worrying.
- B. Contact the relative to determine their capacity to be an adequate care provider.
- C. Encourage the client to call the children to make sure they are doing well.
- D. Gather more information about the client's feelings about the childcare arrangements.
Correct Answer: D
Rationale: The health history is conducted to ascertain a client's state of wellness or illness. A personal dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client. The therapeutic communication must be adapted to the responses, problems, and needs of the client. Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the client's needs. (CN: Psychosocial adaptation; CL: Synthesize)
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The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
- A. Medication therapy.
- B. Diet modification.
- C. Activity restrictions.
- D. Dental care.
Correct Answer: A
Rationale: Medication therapy (e.g., anticoagulants, diuretics) is critical to manage symptoms and prevent complications like thromboembolism in mitral stenosis.
Which of the following dietary measures would be useful in preventing esophageal reflux?
- A. Eating small, frequent meals.
- B. Increasing fluid intake.
- C. Avoiding air swallowing with meals.
- D. Adding a bedtime snack to the dietary plan.
Correct Answer: A
Rationale: Small, frequent meals reduce gastric distention and lower the risk of reflux compared to large meals. The other options are less effective or may worsen symptoms.
Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.