Nokea
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
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A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.
A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.
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 provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)
- A. Cleanse the mask or collar with soapy water every other day.
- B. Make sure the straps on the mask are secure but not too tight.
- C. Check the tops of his ears regularly for skin breakdown.
- D. Post 'no smoking' warning signs at home in a prominent location.
- E. Apply petroleum jelly around and inside the nares.
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making sure the straps on the mask are secure but not too tight is essential to ensure proper oxygen delivery without discomfort or skin irritation.
C: Checking the tops of the ears regularly for skin breakdown is important as the oxygen tubing can cause pressure and skin breakdown in this area.
D: Posting 'no smoking' warning signs at home in a prominent location is crucial as oxygen is highly flammable and can lead to a fire hazard if exposed to smoking or open flames.
Summary:
A: Cleansing the mask or collar with soapy water every other day is not necessary for home oxygen therapy as frequent cleaning can damage the equipment.
E: Applying petroleum jelly around and inside the nares is not recommended as it can interfere with oxygen delivery and cause respiratory issues.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.