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A nurse is planning to reinforce teaching with a client who has a low health literacy level. Which of the following methods should the nurse use?
- A. Provide four important points.
- B. Explain information using passive voice.
- C. Use third person.
- D. Have two information sessions.
Correct Answer: A
Rationale: The correct answer is A because providing four important points can help simplify and organize information for a client with low health literacy. Breaking down information into key points can enhance understanding and retention. Choice B using passive voice may confuse the client. Choice C using third person may create distance and hinder engagement. Choice D having two information sessions could overwhelm the client. In summary, choice A is the most effective method for reinforcing teaching with a client with low health literacy.
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A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?
- A. Leaves the client's dentures in his mouth
- B. Prepares to cleanse the client's body
- C. Disconnects the cardiac monitor from the client
- D. Removes soiled linens from the client
Correct Answer: B
Rationale: In Islamic practices, same-gender family members or religious personnel should perform body cleansing. A female nurse cleansing a male client would require intervention.
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 can significantly impact a client's ability to concentrate and retain information during a teaching session. Pain can cause distress, affecting the client's focus and ability to engage in the learning process. Therefore, addressing pain as a priority before proceeding with discharge teaching is essential.
Hearing loss (B) can be accommodated with visual aids or written materials. Cultural considerations (C) can be integrated into the teaching plan. Motor impairment (D) can also be managed by providing alternative methods for learning. Other choices are not as critical as pain in hindering the learning process.
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, “Go away! No one can help me.†Which of the following responses should the nurse make?
- A. Everything will be ok.
- B. I will come back later and we can talk.
- C. Why are you crying?
- D. Do you think crying will help?
Correct Answer: B
Rationale: The correct answer is B: "I will come back later and we can talk." This response shows empathy, respect for the client's autonomy, and a willingness to provide support without being intrusive. By offering to come back later, the nurse acknowledges the client's feelings and demonstrates a willingness to engage in a supportive conversation when the client is ready.
Choice A is incorrect because it dismisses the client's feelings without offering meaningful support. Choice C may come off as confrontational and put the client on the defensive. Choice D is dismissive and lacks empathy, potentially making the client feel unsupported. Overall, choice B is the best response as it respects the client's feelings and allows for a supportive conversation at a later time.
A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?
- A. 108/60 mm Hg
- B. 128/88 mm Hg
- C. 154/96 mm Hg
- D. 164/104 mm Hg
Correct Answer: C
Rationale: The correct answer is C (154/96 mm Hg) for stage 1 hypertension. Stage 1 hypertension is defined as systolic blood pressure ranging from 130-139 mm Hg or diastolic blood pressure ranging from 80-89 mm Hg. Option C falls within this range, making it the correct choice. Option A (108/60 mm Hg) is normal blood pressure. Option B (128/88 mm Hg) is prehypertension. Option D (164/104 mm Hg) falls within the stage 2 hypertension range, which is higher than stage 1 hypertension.
A nurse is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grief?
- A. A client who has recently given up a child for adoption
- B. A client who experiences traumatic amputation of an extremity
- C. A client whose son committed suicide
- D. A client who has a new diagnosis of metastatic liver cancer
Correct Answer: D
Rationale: Anticipatory grief occurs when an individual knows a loss is imminent, as in terminal cancer.