Nokea
A nurse is collecting data from the daughter of an older adult client. Which of the following statements by the daughter is a priority to the nurse?
- A. My mother is unable to bathe herself.'
- B. We sit outside every afternoon.'
- C. We buy the prescriptions we can afford.'
- D. My mother seems depressed.'
Correct Answer: C
Rationale: Financial constraints affecting medication adherence pose an immediate health risk and require intervention.
You may also like to solve these questions
A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). Which of the following should the nurse instruct the client to avoid for at least 3 days before the test?
- A. Whole grain cereal
- B. Magnesium hydroxide
- C. Orange juice
- D. Acetaminophen
Correct Answer: B
Rationale: The correct answer is B: Magnesium hydroxide. This is because magnesium hydroxide, commonly found in antacids and laxatives, can cause false-positive results in a fecal occult blood test (FOBT) due to its chemical reaction with the test reagents. Instructing the client to avoid magnesium hydroxide for at least 3 days before the test ensures accurate results.
Incorrect choices:
A: Whole grain cereal - Whole grain cereal does not interfere with FOBT results.
C: Orange juice - Orange juice does not impact FOBT results.
D: Acetaminophen - Acetaminophen does not affect FOBT results.
Therefore, avoiding magnesium hydroxide is crucial to obtaining reliable results in the FOBT.
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 identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.
- A. Aspirate the solution from the catheter.
- B. Stop the infusion.
- C. Disconnect the tubing from the catheter.
- D. Remove the IV catheter.
- E. Attach a syringe to the catheter.
Correct Answer: B,E,A,C,D
Rationale: The correct sequence is B, E, A, C, D. First, stopping the infusion prevents further harm. Then, attaching a syringe helps to aspirate the vesicant solution. Aspirating the solution reduces tissue damage. Disconnecting the tubing prevents further exposure. Lastly, removing the IV catheter minimizes harm and promotes healing. Incorrect choices: A is incorrect as the solution should be aspirated after stopping the infusion. C is incorrect as disconnecting the tubing should come after aspirating the solution. D is incorrect as removing the IV catheter is the final step after all the previous actions have been completed.
A nurse is reinforcing teaching with an older adult client. Which of the following strategies should the nurse use?
- A. Incorporate teaching needs into one daily session.
- B. Emphasize visual and auditory teaching techniques.
- C. Minimize distractions by closing the door to the room.
- D. Begin with the most difficult learning tasks.
Correct Answer: B
Rationale: The correct answer is B: Emphasize visual and auditory teaching techniques. Older adults may have sensory impairments, so using visual aids and auditory cues can enhance learning. Visual aids help reinforce concepts, and auditory cues can aid in memory retention. This strategy accommodates potential hearing or vision deficits in older adults, promoting effective learning.
A: Incorporating teaching needs into one daily session may overwhelm the client.
C: Closing the door may not address other potential distractions in the environment.
D: Beginning with the most difficult tasks may discourage the client and hinder learning progress.
A nurse is reinforcing dietary teaching with a client who wants to reduce solid fat intake. Which of the following instructions should the nurse include?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier alternative to butter as it is a liquid fat and contains unsaturated fats, which are better for heart health and reducing solid fat intake. Butter, on the other hand, is a solid fat high in saturated fats, which can increase cholesterol levels. This substitution promotes a lower intake of solid fats while still allowing for baking needs. The other choices are incorrect because: A) Stick margarine is also a solid fat high in trans fats, not suitable for reducing solid fat intake. C) Whole milk contains solid fats, so opting for low-fat or skim milk would be better. D) Ground beef with at least 80% lean meat still contains solid fats, so choosing leaner options like 90% lean or ground turkey would be more beneficial.