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A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Why do you think they're not eating?
- B. Tell me more about what happens at mealtime.
- C. They may need a feeding tube.
- D. I'm sure it's nothing serious and their appetite will return soon.
Correct Answer: B
Rationale: Exploring mealtime details gathers specific data to address the eating issue effectively.
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A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Keep legs straight.
- B. Bend at the waist.
- C. Tighten the abdominal muscles.
- D. Hold object away from the body.
Correct Answer: C
Rationale: Tightening abdominal muscles stabilizes the spine, reducing back injury risk during lifting.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Postpone the procedure until the staff contacts the guardian.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: Implied consent applies in emergencies when the guardian is unavailable, allowing life-saving treatment.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. We should talk about your decision later.
- B. Your quality of life will be compromised if you make this decision.
- C. How will you discuss this decision with your loved ones?
- D. Don't worry. Everything will work out for you.
Correct Answer: C
Rationale: Asking about discussing the decision respects autonomy and encourages communication.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in responding, enhancing understanding.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.