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A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?
- A. I have signed up to be a dog walker when I normally would watch television.'
- B. I understand that losing weight would improve my health and well-being.'
- C. I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks.'
- D. My spouse and children are always encouraging me to eat healthier.'
Correct Answer: A
Rationale: Signing up as a dog walker (A) shows a concrete behavioral change, indicating readiness. Understanding benefits (B), short-term goals (C), or external encouragement (D) are less indicative of sustained motivation.
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An adult client has been medicated for elective surgery. The operating room nurse discovers that the consent form for surgery has not been signed. What should the nurse do?
- A. Have the client sign the consent form
- B. Tell the physician that the consent form has not been signed
- C. Have the client's spouse sign the consent form
- D. Continue preparation for surgery because the client has given implied consent
Correct Answer: B
Rationale: Preoperative medications impair judgment, making consent invalid post-administration. Notifying the physician ensures legal and ethical consent is obtained, delaying surgery if needed.
The practical nurse is collaborating with the registered nurse to form a care plan for a client with a possible diagnosis of Guillain-Barré syndrome. The nurse should give priority to which client assessment?
- A. Orthostatic blood pressure changes
- B. Presence or absence of knee reflexes
- C. Pupil size and reaction to light
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Respiratory assessment (D) is the priority in Guillain-Barré syndrome due to the risk of respiratory muscle paralysis. Reflexes (B) are relevant but less urgent, and blood pressure (A) and pupils (C) are not primary concerns.
The LPN/LVN is providing home care to an elderly widow who has senile dementia. The woman tells the nurse that her daughter hits her and tells her to shut up. The nurse notes one ecchymotic area on the client's right forearm. The daughter seems attentive to the woman when the nurse is present. What action should the nurse take?
- A. Immediately call the police
- B. Ask the daughter why she abuses her mother
- C. Ask the physician to order long bone x-rays
- D. Report the woman's remarks and the nurse's findings to the nursing supervisor
Correct Answer: D
Rationale: Reporting suspected abuse to the supervisor initiates investigation and protection, the appropriate action for potential elder abuse.
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.
- A. 4-month-old client who is receiving scheduled vaccinations
- B. 3-year-old client who is afraid of needles
- C. 24-year-old client who is 6 weeks postpartum
- D. 32-year-old client who is pregnant at 12 weeks gestation
- E. 45-year-old client with a history of HIV
Correct Answer: B, C
Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (B) and postpartum client (C). It's contraindicated for infants under 2 (A), pregnant women (D), and immunocompromised clients (E).