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A nurse is assisting a client in planning an exercise routine. Which of the following activities should the nurse encourage the client to avoid due to age-related changes?
- A. Stretching
- B. Running
- C. Resistance training
- D. Aerobic exercises
Correct Answer: B
Rationale: The correct answer is B: Running. Age-related changes such as decreased bone density and joint stiffness can make running high-impact and potentially harmful. Stretching (A) is important for flexibility, resistance training (C) helps maintain muscle mass, and aerobic exercises (D) improve cardiovascular health. Running may exacerbate joint issues.
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A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and allows the client to share their reason for seeking care, which can provide valuable information for the nurse to understand the client's current health status and concerns. It also helps establish rapport and encourages the client to share their perspective.
Rationale for other choices:
B: Asking about all medical issues is too broad and may overwhelm the client, leading to a less focused discussion.
C: Asking if the client wants to talk about health concerns puts the onus on the client to bring up topics, which may hinder open communication.
D: While discussing feelings is important, it may not be the most immediate priority during admission and may not capture the primary reason for seeking care.
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
- A. Measure from the client's heel to the gluteal fold.
- B. Measure the length of the client's feet.
- C. Measure from the client's heel to the popliteal space.
- D. Measure the client's ankle circumference.
Correct Answer: C
Rationale: The correct answer is C: Measure from the client's heel to the popliteal space. This is the correct action because knee-high antiembolic stockings should cover the area from the heel to just below the knee at the popliteal space. This measurement ensures proper sizing and compression effectiveness.
A: Measuring from the heel to the gluteal fold is incorrect as it would result in stockings that are too long and may impede circulation.
B: Measuring the length of the client's feet is irrelevant for determining the correct size of knee-high stockings.
D: Measuring the client's ankle circumference alone is insufficient for determining the appropriate length of knee-high stockings.
In summary, choice C is correct as it ensures the stockings fit properly, while the other choices are incorrect due to inaccuracies or irrelevance in determining the appropriate size for knee-high antiembolic stockings.
A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
- A. Move body parts rapidly through the movements.
- B. Support extremities above and below joints.
- C. Stretch the body part just beyond the existing range of motion.
- D. Continue moving body parts if muscle spasticity occurs.
Correct Answer: B
Rationale: The correct answer is B: Support extremities above and below joints. This is because supporting the extremities above and below the joints helps to maintain proper alignment and stability during passive range of motion exercises, preventing injury and ensuring effective movement. Moving body parts rapidly (choice A) can cause muscle strain or injury. Stretching the body part beyond existing range (choice C) can lead to muscle or ligament damage. Continuing movement if spasticity occurs (choice D) can exacerbate muscle tightness. This is why choice B is the most appropriate action to take during passive range of motion exercises.
A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the most appropriate information to include in the brochure because gently rolling the testicles between the thumb and fingers is the recommended technique for testicular self-examination. By rolling the testicles, individuals can better detect any lumps or changes in texture that may indicate testicular cancer.
Choice A is incorrect because the current recommendation is to perform testicular self-exams monthly, not twice per year. Choice B is incorrect as palpating the epididymis is not part of the standard testicular self-examination procedure. Choice D is incorrect because using both hands is recommended for better examination.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important to facilitate the grieving process and provide closure. Allowing the family to view the body privately enables them to say goodbye in their own way and can help them come to terms with the loss. It shows respect for the family's cultural and religious beliefs regarding death and mourning. It also allows for a more personal and intimate experience for the family members.
Choice A is incorrect because asking the family to return after the staff cleans the body may cause unnecessary delays and distress for the family. Choice B is incorrect as performing postmortem care should not take precedence over allowing the family to view the body. Choice C, having a clergy member present, is a supportive gesture but does not address the immediate needs of the family to see the deceased.