Nokea
A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
- A. The client is grasping his abdomen
- B. The client is hyperventilating
- C. The client is coughing
- D. The client cannot speak
Correct Answer: D
Rationale: Inability to speak is a sign of complete airway obstruction requiring abdominal thrusts. Coughing indicates partial obstruction and does not require immediate thrusts.
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A nurse in a clinic is reinforcing teaching with a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?
- A. I'll sit with my knees lower than my hips.'
- B. I'll do exercises that strengthen my abdominal muscles.'
- C. I'll wear low-heeled shoes from now on.'
- D. I'll carry heavy objects close to my body.'
Correct Answer: A
Rationale: The correct answer is A: "I'll sit with my knees lower than my hips." This statement indicates a misunderstanding as it can actually contribute to low back pain. Sitting with knees lower than hips can increase pressure on the lower back. The correct sitting posture to prevent low back pain is to have knees at or slightly above hip level. This helps maintain the natural curve of the spine.
Explanation for other choices:
B: "I'll do exercises that strengthen my abdominal muscles." - Correct, as strong core muscles can help support the lower back.
C: "I'll wear low-heeled shoes from now on." - Correct, as high heels can alter posture and contribute to back pain.
D: "I'll carry heavy objects close to my body." - Correct, as this reduces strain on the back when lifting.
A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?
- A. Reiki
- B. Biofeedback
- C. Acupuncture
- D. Yoga
Correct Answer: B
Rationale: Biofeedback uses electronic monitoring to help individuals gain control over physiological functions such as heart rate and muscle tension.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C. Listening attentively when the client talks about the past is essential in helping the older adult cope with feelings of grief. By actively listening, the nurse validates the client's feelings and provides a supportive environment for the client to express and process their emotions. This approach shows empathy and understanding, which can help the client feel heard and respected.
Choice A is incorrect because simply stating that it is a common problem does not address the client's individual feelings and may diminish the significance of their grief. Choice B is incorrect as it suggests avoidance rather than addressing the client's emotions directly. Choice D is incorrect as comparing the client's experience to that of younger clients may not be relevant or helpful.
A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?
- A. At the beginning of the collection time, urinate and then discard the urine.
- B. Keep the collection container at room temperature.
- C. Save each urine collection in a separate container.
- D. At the end of the collection time, urinate and save the urine in a separate container.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Urinating and discarding the first urine sample helps ensure that the 24-hour collection period begins accurately. This initial voiding clears out any urine that has been in the bladder prior to the start of the collection. This step is crucial to obtain an accurate measurement of substances excreted over the 24-hour period.
Summary:
B: Keeping the collection container at room temperature is not crucial for accurate urine collection.
C: Saving each urine collection in a separate container may lead to inaccuracies in the final analysis.
D: Urinating and saving the final urine sample separately at the end of the collection period may skew the results.
A nurse is assisting with an education program about breast self-examinations. Which of the following information should the nurse include?
- A. Perform breast self-examinations 1 week following menses.
- B. Palpate the breasts using a left to right motion.
- C. Express discharge from the nipple each month.
- D. Avoid performing breast self-examinations while showering.
Correct Answer: A
Rationale: The correct answer is A: Perform breast self-examinations 1 week following menses. This timing is ideal because breasts are less likely to be tender or swollen during this time, making it easier to detect any abnormalities. Performing the exam at the same time each month helps in noticing changes. Option B is incorrect because the recommended motion is in a circular pattern. Option C is incorrect because expressing discharge is not a part of breast self-examination. Option D is incorrect as performing the exam in the shower is actually beneficial due to the slippery nature of wet skin, aiding in smooth palpation.