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A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
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A nurse is caring for a client who has atelectasis. The nurse should instruct the client to lie on his back with a quarter turn elevating his right side and his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: Postural drainage in this position helps mobilize secretions from the lower lobes and prevent complications.
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?
- A. Urinary tract infection
- B. Urinary incontinence
- C. Urinary frequency
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Urinary tract infection. The dark amber color, cloudy appearance, and unpleasant odor of the urine indicate a possible infection. Dark amber color suggests concentrated urine due to dehydration, common in UTIs. Cloudiness indicates presence of bacteria or pus, typical in UTIs. Unpleasant odor is often caused by bacteria breaking down urine. Choices B, C, and D are unlikely to cause these specific findings. Urinary incontinence refers to involuntary leakage of urine and does not directly affect urine appearance. Urinary frequency means urinating more often but doesn't typically change urine color or odor. Urinary retention is the inability to empty the bladder completely, which may lead to overflow incontinence, but doesn't directly cause dark amber, cloudy, and foul-smelling urine.
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 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: Listen attentively when the client talks about the past. Active listening is crucial in helping the client cope with feelings of grief. By providing a supportive environment and allowing the client to express his emotions, the nurse can validate his feelings and provide emotional support. This helps the client feel understood and accepted, facilitating the grieving process.
Choice A is incorrect because simply stating that it is a common problem does not address the individual client's feelings. Choice B is incorrect as it dismisses the client's emotions and distracts rather than addressing the root of the issue. Choice D is inappropriate as it is not empathetic and may invalidate the client's experience by comparing it to others.
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.