Nokea
A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?
- A. Watch training videos of people driving in various environments
- B. Begin visualizing himself driving each route to the freeway
- C. Take antianxiety medication two hours before driving on freeways
- D. Get in the car with a support person and drive on a freeway during rush hour
Correct Answer: B
Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.
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The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?
- A. Provide educational materials on smoking cessation
- B. Offer blood pressure screening and monitoring
- C. Provide information on safe sex practices
- D. Discuss the importance of a healthy diet and exercise
Correct Answer: B
Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.
A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?
- A. Two to three soft bowel movements per day
- B. Increased serum ammonia levels
- C. Decreased white blood cell count
- D. Soft, formed stool twice a day
Correct Answer: A
Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.
The nurse is assessing a client who has a prescription for digoxin (Lanoxin). Which finding indicates that the client is at risk for digoxin toxicity?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 120/80 mm Hg
- C. Respiratory rate of 18 breaths per minute
- D. Serum potassium level of 3.0 mEq/L
Correct Answer: D
Rationale: A low serum potassium level increases the risk of digoxin toxicity. Digoxin toxicity is more likely to occur in individuals with low potassium levels because potassium is crucial for proper heart function. A heart rate of 60 beats per minute, blood pressure of 120/80 mm Hg, and respiratory rate of 18 breaths per minute are within normal ranges and do not directly indicate an increased risk of digoxin toxicity.
A nurse is caring for a client with a new colostomy. Which instruction should the nurse include in the client's teaching plan?
- A. Change the ostomy appliance daily
- B. Empty the ostomy pouch when it is one-third full
- C. Rinse the ostomy pouch with warm water
- D. Apply a skin barrier to the peristomal skin
Correct Answer: B
Rationale: The correct instruction the nurse should include in the client's teaching plan is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining an appropriate pouching system. Changing the ostomy appliance daily (Choice A) is not necessary unless leakage or other issues occur. Rinsing the ostomy pouch with warm water (Choice C) is not a recommended practice as it may cause damage to the pouch. Applying a skin barrier to the peristomal skin (Choice D) is important but not the most crucial instruction in this scenario.
The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?
- A. Bananas and pineapple
- B. Cottage cheese and crackers
- C. Peanut butter and jelly
- D. Tomato and lettuce salad
Correct Answer: D
Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.