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A nurse is reinforcing teaching about health promotion with a group of older adults. Which of the following health promotion measures should the nurse recommend? (Select all that apply.)
- A. Yearly blood pressure screening
- B. Use of lotions with a SPF of 15 or higher
- C. Immunization for influenza
- D. Annual visual acuity screening
- E. Reduce calcium intake.
Correct Answer: A,B,C,D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Yearly blood pressure screening is important for early detection and management of hypertension, a common health issue in older adults.
B: Using lotions with SPF of 15 or higher helps prevent skin damage and reduces the risk of skin cancer, a common concern in older adults.
C: Immunization for influenza is crucial in older adults to prevent serious complications from the flu due to their weakened immune systems.
D: Annual visual acuity screening is essential for detecting age-related vision changes and preventing accidents or falls.
Summary:
E: Reducing calcium intake is not a recommended health promotion measure for older adults, as adequate calcium is essential for bone health and preventing osteoporosis.
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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 measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
- A. Measure from the client's heel to the gluteal fold.
- B. Measure the length of the client's feet.
- C. Measure from the client's heel to the popliteal space.
- D. Measure the client's ankle circumference.
Correct Answer: C
Rationale: The correct answer is C: Measure from the client's heel to the popliteal space. This is the correct action because knee-high antiembolic stockings should cover the area from the heel to just below the knee at the popliteal space. This measurement ensures proper sizing and compression effectiveness.
A: Measuring from the heel to the gluteal fold is incorrect as it would result in stockings that are too long and may impede circulation.
B: Measuring the length of the client's feet is irrelevant for determining the correct size of knee-high stockings.
D: Measuring the client's ankle circumference alone is insufficient for determining the appropriate length of knee-high stockings.
In summary, choice C is correct as it ensures the stockings fit properly, while the other choices are incorrect due to inaccuracies or irrelevance in determining the appropriate size for knee-high antiembolic stockings.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?
- A. Nonverbal communication conveys less truth than what the client states verbally.
- B. The client's sociocultural background influences nonverbal communication.
- C. Nonverbal communication is a poor reflection of what the client feels.
- D. The client enacts nonverbal communication consciously.
Correct Answer: B
Rationale: The correct answer is B: The client's sociocultural background influences nonverbal communication. Nonverbal communication is greatly impacted by an individual's cultural norms, values, and beliefs. This influences gestures, facial expressions, posture, and personal space preferences. Understanding the client's sociocultural background helps the nurse interpret nonverbal cues accurately.
Choice A is incorrect because nonverbal communication can often convey more truth than verbal statements as it can be more spontaneous and genuine. Choice C is incorrect because nonverbal behavior can provide valuable insights into a client's true feelings and emotions. Choice D is incorrect because nonverbal communication is often unconscious and can be influenced by subconscious factors.
A charge nurse is assisting a newly-licensed nurse to insert an indwelling urinary catheter for a male client. Which of the following actions requires the charge nurse to intervene?
- A. Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing
- B. Lubricates the first 15 to 17.5 cm (6 to 7 in) of the catheter
- C. Secures the tubing to the client's upper thigh
- D. Secures the tubing to the client's lower abdomen.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct action for inserting an indwelling urinary catheter in a male client is to lubricate the first 15 to 17.5 cm (6 to 7 in) of the catheter, not just the first 2.5 to 5 cm (1 to 2 in). This is crucial to ensure smooth insertion and prevent trauma to the urethra. Therefore, the charge nurse should intervene and guide the newly-licensed nurse to lubricate the appropriate length of the catheter tubing.
Summary of Incorrect Choices:
B: Lubricating the first 15 to 17.5 cm (6 to 7 in) of the catheter is the correct action, not an intervention.
C: Securing the tubing to the client's upper thigh is a proper step to prevent pulling on the catheter, not requiring intervention.
D: Securing the tubing to the client's lower abdomen is also a standard practice to prevent dislod
A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminds the client of the importance of doing warm-up exercises, the client asks why. Which of the following reasons should the nurse give?
- A. Stabilizes body temperature
- B. Enhances relaxation
- C. Reduces the risk of injury
- D. Readjusts to baseline function
Correct Answer: C
Rationale: The correct answer is C: Reduces the risk of injury. Warm-up exercises help increase blood flow to muscles, making them more flexible and responsive. This reduces the risk of muscle strains and injuries during exercise. Choice A is incorrect because while warm-up exercises may help regulate body temperature during exercise, that is not the primary reason for warm-ups. Choice B is incorrect as the primary purpose of warm-up exercises is not necessarily to enhance relaxation. Choice D is incorrect as warm-up exercises do not specifically readjust to baseline function; they prepare the body for exercise.