Nokea
A client who has Ménière's disease is trying to cope with the chronic tinnitus that she is experiencing. Which of the following interventions is most appropriate for the nurse to suggest for coping with the tinnitus?
- A. Maintain a quiet environment.
- B. Play background music.
- C. Avoid caffeine and nicotine.
- D. Take a mild sedative.
Correct Answer: B
Rationale: Background music can mask tinnitus, helping the client cope by reducing the perception of the noise.
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You are the registered nurse in a multi ethnic community health department clinic. In this role you are asked to identify clients who have genetic risk factors related to ethnicity in order to screen them for some commonly occurring diseases and disorders. You would identify a client who is of:
- A. Mediterranean ethnicity for cystic fibrosis.
- B. African American ethnicity for Tay Sachs disease.
- C. British Isles ethnicity for psychiatric mental health disorders.
- D. Saudi Arabian ethnicity for sickle cell anemia.
Correct Answer: D
Rationale: Sickle cell anemia is strongly associated with populations from regions like Saudi Arabia, Africa, and parts of India. Screening clients of Saudi Arabian ethnicity for sickle cell anemia is appropriate due to the higher prevalence of the sickle cell trait in these populations.
The home health nurse cares for an obese adult client. In the client's medical record, the nurse reads, 'The client has a sprained right ankle, has not exercised for more than 1 week, and has missed the last two physical therapy appointments.' The client says, 'I attend therapy for my ankle and I do my exercises three times a day.' Which response should the nurse use with the client?
- A. Show me the exercises that you perform in physical therapy.
- B. You will never heal if you skip the physical therapy sessions.
- C. Your progress sounds fine. Is more physical therapy scheduled?
- D. I see that you missed the last two physical therapy appointments.
Correct Answer: D
Rationale: In the correct option, the nurse employs the therapeutic communication technique of confrontation. Because the client is employing avoidance, the nurse presents the facts according to the medical record to assess the client's perspective without accusing, threatening, or humiliating the client about the missed physical therapy. By confronting, the nurse assists the client with problem-solving. Option 1 is potentially helpful when the client is complying with therapy. In option 2, the nurse provides an opinion and this statement admonishes the client for the behavior. In option 3, the nurse is nontherapeutic in giving approval and is mirroring the client's avoidance and passivity by not dealing directly with the problem of missed appointments.
A client with pancreatitis is admitted with severe abdominal pain. Which position should the nurse encourage to reduce discomfort?
- A. Supine with legs elevated
- B. Side-lying with knees flexed
- C. Prone with a pillow under the abdomen
- D. Sitting upright
Correct Answer: B
Rationale: Side-lying with knees flexed reduces tension on the abdominal muscles and pancreas, helping to alleviate pain in pancreatitis.
A client with chronic kidney disease is on a low-potassium diet. Which of the following foods should the nurse recommend?
- A. Bananas
- B. Apples
- C. Oranges
- D. Potatoes
Correct Answer: B
Rationale: Apples are low in potassium, suitable for a renal diet. Bananas, oranges, and potatoes are high in potassium and should be avoided.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.