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A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.
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A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.
A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?
- A. Reiki
- B. Biofeedback
- C. Acupuncture
- D. Yoga
Correct Answer: B
Rationale: Biofeedback uses electronic monitoring to help individuals gain control over physiological functions such as heart rate and muscle tension.
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.
A nurse is reinforcing teaching with an older adult client. Which of the following strategies should the nurse use?
- A. Incorporate teaching needs into one daily session.
- B. Emphasize visual and auditory teaching techniques.
- C. Minimize distractions by closing the door to the room.
- D. Begin with the most difficult learning tasks.
Correct Answer: B
Rationale: The correct answer is B: Emphasize visual and auditory teaching techniques. Older adults may have sensory impairments, so using visual aids and auditory cues can enhance learning. Visual aids help reinforce concepts, and auditory cues can aid in memory retention. This strategy accommodates potential hearing or vision deficits in older adults, promoting effective learning.
A: Incorporating teaching needs into one daily session may overwhelm the client.
C: Closing the door may not address other potential distractions in the environment.
D: Beginning with the most difficult tasks may discourage the client and hinder learning progress.
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.