Nokea
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
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A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?
- A. You have nothing to worry about.
- B. Others who have had this procedure have had great results.
- C. Tell me more about your concerns.
- D. Why are you feeling so anxious?
Correct Answer: C
Rationale: The correct response is C: "Tell me more about your concerns." This is the best response because it shows active listening and empathy towards the client's feelings. By encouraging the client to express their concerns, the nurse can address specific fears or worries, providing reassurance and support tailored to the individual's needs. This open-ended question allows the client to share their feelings, leading to better communication and trust between the nurse and client.
Other choices are incorrect because:
A: "You have nothing to worry about." is dismissive and does not acknowledge the client's feelings.
B: "Others who have had this procedure have had great results." may minimize the client's anxiety and not address their specific concerns.
D: "Why are you feeling so anxious?" is a closed-ended question that may put the client on the spot and not facilitate open communication.
A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?
- A. Note dry, flaky skin as an expected finding.
- B. Examine the back before the general inspection of the skin.
- C. Pinch up a fold of skin to check for turgor.
- D. Use a penlight to examine the back in greater detail.
Correct Answer: A
Rationale: The correct answer is A. Dry, flaky skin is a common finding in older adults due to decreased oil gland activity. The nurse should note this as an expected finding because it is often a normal part of aging and not necessarily indicative of a health concern. Option B is unnecessary as the nurse can inspect the back during the general skin assessment. Option C, checking skin turgor, is not relevant to dry, flaky skin. Option D, using a penlight for detailed examination, is excessive for this situation.
A nurse in an extended-care facility is reinforcing teaching with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include? (Select all that apply.)
- A. More difficulty seeing due to a greater sensitivity to glare
- B. Decreased cough reflex
- C. Decreased bladder capacity
- D. Decreased systolic blood pressure
- E. Dehydration of intervertebral discs
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: With aging, the lens of the eye becomes less flexible, leading to difficulty seeing due to glare.
B: Aging affects the cough reflex, making it less effective in clearing the respiratory tract.
C: Bladder capacity decreases with age due to decreased muscle tone and elasticity.
E: Intervertebral discs lose water content with age, leading to dehydration and decreased flexibility.
Incorrect Choices:
D: Systolic blood pressure tends to increase with age, not decrease.
F, G: No information provided to analyze these options.
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A: Pain. Pain can significantly impair a client's ability to concentrate and retain information during a teaching session. It may cause distress and make it difficult for the client to focus on the instructions provided. Therefore, addressing the pain as a priority before proceeding with teaching is crucial for effective learning.
Hearing loss (B), the client's culture (C), and motor impairment (D) can also present barriers to learning, but these can be accommodated through appropriate communication methods and cultural sensitivity. However, pain directly affects the client's cognitive function and must be managed before effective teaching can take place.