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A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response shows empathy and understanding towards the client's concerns and opens up a dialogue to explore the client's feelings and thoughts about retirement. It allows the nurse to assess the client's emotional readiness and concerns, facilitating a supportive conversation.
Other choices are incorrect:
A: This response assumes that the client's main concern is spending time with family, which may not be the case.
B: While volunteering or working part-time are valid options, this response does not address the client's current feelings and may come across as dismissive.
D: This response is judgmental and does not acknowledge the client's perspective or concerns, potentially shutting down communication.
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A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
- A. I will return shortly after I document this in your record.
- B. Most men live a long time with prostate cancer.
- C. I am available to talk if you should change your mind.
- D. I will make a referral to a cancer support group for you.
Correct Answer: C
Rationale: The correct answer is C: "I am available to talk if you should change your mind." This response shows the nurse's willingness to provide support and maintain an open line of communication without being intrusive. It respects the client's current decision while also conveying availability for future discussions, promoting trust and rapport.
A: Incorrect. This response prioritizes documentation over the client's emotional needs.
B: Incorrect. While well-intentioned, this statement may offer false reassurance and overlooks individual variability in prognosis.
D: Incorrect. Referring to a support group without the client's consent may not align with their current preferences.
E: Incorrect. Incomplete choice.
F: Incorrect. Incomplete choice.
G: Incorrect. Incomplete choice.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often
- B. since it is not controlling my pain.
- C. Breathing faster will help me keep my mind off of the pain.
- D. It might help me to listen to music while I'm lying in bed.
- E. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C. The client's statement about breathing faster to keep their mind off the pain indicates understanding of distraction techniques taught preoperatively. This method helps manage pain perception. Choices A and B suggest incorrect self-medication adjustments. Choices D and E do not demonstrate understanding of pain management strategies.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Reflexology
- D. Acupuncture
Correct Answer: D
Rationale: The correct answer is D: Acupuncture. Herpes zoster, also known as shingles, is a viral infection that affects the nerves and causes a painful rash. Acupuncture involves inserting thin needles into specific points on the body to alleviate pain and promote healing. However, in the case of herpes zoster, the skin lesions and nerve involvement increase the risk of spreading the virus through acupuncture needles, leading to potential complications. Therefore, acupuncture is contraindicated in clients with herpes zoster to prevent the spread of the virus.
A: Biofeedback, B: Aloe, and C: Reflexology are not contraindicated for clients with herpes zoster. Biofeedback is a non-invasive technique that helps individuals control physiological processes such as reducing stress and managing pain. Aloe is a natural plant extract commonly used for its anti-inflammatory and soothing properties, which can be beneficial for skin irritations caused by herpes zoster. Reflexology is a therapeutic technique that involves applying pressure to