Nokea
A nurse is assisting with the readmission of a client to the medical unit after a transfer to ICU following a suicide attempt using an overdose of medication. The client looks down at the floor and mumbles, 'Hello.' Which of the following responses should the nurse make?
- A. You have been transferred back to this unit. This is your new room.
- B. Hello. I see that in ICU you've been getting a light diet. How does your stomach feel now?
- C. I was upset when I found you had tried to kill yourself.
- D. Would you like to talk about what happened?
Correct Answer: D
Rationale: Encouraging open communication provides emotional support and helps the client process their feelings.
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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.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. This is the appropriate action because the patient, being African-American, is at increased risk for hypertension. Providing information on lifestyle modifications such as a healthy diet, regular exercise, and stress management can help prevent the development of hypertension. This proactive approach aligns with preventative care and promotes the patient's overall well-being.
Choice A is incorrect because annual appointments may not address potential risk factors for hypertension. Choice C, scheduling a PSA test, is not relevant to the patient's current health assessment. Choice D, providing a weight loss plan, may be beneficial but not directly related to hypertension risk reduction in this scenario.
A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Grape juice
- B. Lemon sherbet
- C. Skim milk
- D. Carrot juice
Correct Answer: A
Rationale: The correct answer is A: Grape juice. A clear liquid diet includes transparent liquids like water, broth, tea, and clear juices without pulp. Grape juice fits this criteria as it is a clear liquid that is easily digestible. Lemon sherbet (B) contains dairy and solid components, not suitable for a clear liquid diet. Skim milk (C) is a dairy product and not transparent. Carrot juice (D) has pulp and is not considered a clear liquid.
A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.)
- A. Administer opioids with caution because they will eventually lead to addiction.
- B. Consider the client's individual expression of pain.
- C. To achieve fast-acting pain relief, administer analgesics PO.
- D. Use a scale from 0 to 10 to monitor the severity of the client's pain.
- E. Expect the client to express his pain both verbally and nonverbally.
Correct Answer: B,D,E
Rationale: The correct principles to apply in managing a postoperative client's pain are B, D, and E. B is correct because pain is subjective and varies among individuals, so considering the client's individual expression of pain is crucial. D is correct because using a pain scale helps to monitor and assess the severity of the client's pain objectively. E is correct because clients may express pain in different ways, both verbally and nonverbally. These principles help tailor pain management strategies to the client's needs. Choices A and C are incorrect because opioids are necessary for acute pain management postoperatively and administering analgesics PO may not always provide fast-acting relief. Choice F and G are not provided.
A provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?
- A. Increased muscle strength and tone to reduce muscle wasting
- B. Muscle hypertrophy to compensate for decreased joint strength
- C. Promotion of venous stasis to reduce the risk of embolus formation
- D. Reduction in bone density loss to prevent osteoporosis
Correct Answer: A
Rationale: The correct answer is A: Increased muscle strength and tone to reduce muscle wasting. Isometric exercises involve muscle contraction without joint movement, which helps improve muscle strength and tone. This is crucial in preventing muscle wasting commonly seen in clients with knee injuries. Muscle hypertrophy (B) is more associated with resistance training, not isometric exercises. Promotion of venous stasis (C) is incorrect as isometric exercises actually promote circulation and reduce the risk of blood clots. Reduction in bone density loss (D) is not directly related to isometric exercises.