Nokea
A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?
- A. I will take a walk to reduce my anxiety
- B. I will imagine myself in a calm place when I can't concentrate
- C. I will meditate every other week
- D. I will cut back on my caffeine intake
Correct Answer: B
Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.
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What are key signs of fluid overload?
- A. Edema
- B. Hypertension
- C. Shortness of breath
- D. All of the above
Correct Answer: D
Rationale: The correct answer is 'D: All of the above.' Edema, hypertension, and shortness of breath are key signs of fluid overload, particularly common in patients with heart failure. Edema refers to the swelling caused by excess fluid trapped in the body's tissues, hypertension can be a result of fluid volume overload, and shortness of breath can occur due to fluid accumulation in the lungs. Therefore, all these signs collectively indicate fluid overload in a patient. Choices A, B, and C are incorrect individually as each alone may not necessarily indicate fluid overload, but when seen together, they strongly suggest fluid volume excess in the body.
Which of the following is the best intervention for managing dehydration?
- A. Administer antiemetics to prevent nausea
- B. Monitor fluid and electrolyte levels
- C. Encourage the client to drink more fluids
- D. Administer intravenous fluids
Correct Answer: B
Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.
What is the role of a nurse in managing a patient with kidney disease?
- A. Monitor blood pressure and provide dietary education
- B. Monitor urine output and provide IV fluids
- C. Administer diuretics and restrict fluid intake
- D. Monitor for cardiac arrhythmias and provide dialysis
Correct Answer: A
Rationale: The correct answer is A. Nurses play a crucial role in managing patients with kidney disease by monitoring blood pressure and providing essential dietary education. This helps in maintaining kidney function and overall health. Choice B is incorrect because monitoring urine output and providing IV fluids are tasks usually performed by healthcare providers such as physicians or specialized staff. Choice C is incorrect as administering diuretics and restricting fluid intake are typically prescribed by a physician, and nurses may assist in monitoring the effects. Choice D is incorrect as monitoring for cardiac arrhythmias and providing dialysis are tasks that are usually overseen by healthcare providers with specialized training in cardiology and nephrology.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication into the client's nondominant arm.
- B. Pull the skin laterally before inserting the needle.
- C. Massage the injection site after administration.
- D. Pinch the skin between the thumb and forefinger.
Correct Answer: D
Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.
A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?
- A. Place a bed exit alarm
- B. Use restraints to prevent the client from getting out of bed
- C. Ask the client's family to stay at the bedside
- D. Encourage frequent ambulation with assistance
Correct Answer: A
Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.