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A nurse is caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?
- A. Reinforce information at the client's level of understanding.
- B. Notify the client's family of the plan of care.
- C. Describe the surgery and what the client will experience postoperatively.
- D. Reassure the client that the surgery rarely has any negative outcomes.
Correct Answer: A
Rationale: Providing information at the client's level of understanding ensures comprehension and informed decision-making.
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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 measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
- A. Use a cotton-tipped applicator to remove cerumen.
- B. Pull the pinna downward and backward.
- C. Aim the probe posteriorly in the direction of the eardrum.
- D. Insert the probe with a circular motion.
Correct Answer: C
Rationale: The correct answer is C because aiming the probe posteriorly in the direction of the eardrum allows for accurate tympanic temperature measurement. This ensures that the infrared sensor is positioned correctly to capture the heat emitted from the tympanic membrane. Choice A is incorrect as removing cerumen is not necessary for temperature measurement. Choice B is incorrect as pulling the pinna downward and backward is not required for tympanic temperature measurement. Choice D is incorrect as inserting the probe with a circular motion may cause discomfort or injury to the ear canal.
A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?
- A. Tennis
- B. Canoeing
- C. Swimming
- D. Archery
Correct Answer: C
Rationale: The correct answer is C: Swimming. Swimming is a low-impact exercise that helps strengthen the muscles in the back and core without putting excessive strain on the spine. It also promotes flexibility and improves cardiovascular health, which can aid in managing chronic low back pain. Other options like A (Tennis), B (Canoeing), and D (Archery) involve movements that may exacerbate back pain due to potential twisting, impact, or strain on the back muscles. Therefore, swimming is the most suitable recommendation for the client to alleviate and manage chronic low back pain effectively.
A nurse is performing pulmonary hygiene for a client. The nurse should place the client on his right side with pillows elevating the left side of his chest to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right upper lobe
Correct Answer: C
Rationale: Elevation of specific lung areas helps drain mucus and prevent complications such as pneumonia or atelectasis.
A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?
- A. The client takes a 20-min nap each afternoon.
- B. The client has gained 4.5 kg (10 lb) in the past month.
- C. The client is taking a poetry class.
- D. The client takes a walk for 1 hr each day.
Correct Answer: B
Rationale: Sudden weight gain can be a sign of ineffective coping, such as emotional eating.