Nokea
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African-American churches
- B. Asian-American groceries
- C. High school sports camps
- D. Women's health clinics
Correct Answer: A
Rationale: Providing services at African-American churches has the potential to reach this priority population, as African-Americans are at higher risk for hypertension. While hypertension education is important for all groups, this is the priority population for this intervention.
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A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Ambulate the client
- B. Apply a warm moist pack
- C. Massage the client's leg
- D. Provide an ice pack
Correct Answer: B
Rationale: Warm moist packs can help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.
A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
- A. Dietary restrictions
- B. Driving restrictions
- C. Follow-up laboratory monitoring
- D. Drug-drug interactions
- E. Reason to take medication
Correct Answer: A,C,D,E
Rationale: Clients on warfarin need instructions on dietary restrictions, follow-up monitoring, drug interactions, and the reason for the medication, per The Joint Commission's Core Measures. Driving restrictions are not typically required.
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the diagnosis. What action by the nurse is best?
- A. Assess the client's support system
- B. Assist in finding one change the client can control
- C. Determine what stressors the client faces in daily life
- D. Inquire about delegating some of the client's obligations
Correct Answer: B
Rationale: All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Assisting the client in choosing one change they feel optimistic about controlling is the most effective approach to build confidence and promote adherence.
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client's weight has decreased significantly since the last visit. What action by the nurse is best?
- A. Ask if the weight loss was intentional
- B. Encourage a high-protein, high-fiber diet
- C. Measure for new compression stockings
- D. Review a 3-day food recall diary
Correct Answer: C
Rationale: Compression stockings must fit correctly to be effective. After significant weight loss, the client should be re-measured for new stockings. The other options are appropriate but less critical.