Nokea
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
- A. The client moves the cane 2 feet ahea
- B. The client advances the weaker leg forward to the cane.
- C. The client takes a step with their right foot first.
- D. The client holds the cane with their left han
Correct Answer: B
Rationale: The correct answer is B. Advancing the weaker leg forward to the cane provides stability and support, helping distribute weight evenly and preventing falls. This step is crucial in using a quad cane effectively. Moving the cane too far ahead (A) could cause imbalance. Taking a step with the stronger leg first (C) would not provide the needed support for the weaker side. Holding the cane with the same side as the weakness (D) may not provide the necessary support. It is essential to prioritize stability and weight distribution, making option B the correct choice.
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A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
- A. Limit fluid intake to 1,000 mL per day.
- B. Administer oxygen at 2 L/min.
- C. Encourage use of incentive spirometry for 5 min every 2 hr.
- D. Teach the client a breathing exercise with a longer inhalation phase.
Correct Answer: D
Rationale: The correct answer is D. Teaching the client a breathing exercise with a longer inhalation phase helps improve lung capacity and strengthen respiratory muscles, which are essential for clients with emphysema. This intervention can help the client breathe more effectively and reduce shortness of breath. Option A is incorrect because limiting fluid intake is not a standard intervention for emphysema. Option B is incorrect as administering oxygen is not specific to improving lung function. Option C is incorrect as incentive spirometry is more effective if done for longer durations.
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
- A. Your breathing pattern causes this.'
- B. This means your lung is fully re-expande '
- C. Suction pressure that is too high causes this.'
- D. This indicates a possible air leak.'
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system. Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber. Choice B is incorrect as lung re-expansion does not directly cause the fluid movement. Choice C is incorrect as high suction pressure does not cause this specific phenomenon. Choice D is incorrect as fluid movement does not indicate an air leak.
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?
- A. The dietitian will provide you with the best food choices to manage your diabetes.'
- B. I understand that the dietary choices can seem overwhelming.'
- C. I can assist you with making a list of foods you like for the dietitian.'
- D. Managing your diabetes will require you to make accommodations.'
Correct Answer: C
Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.
Choice A is incorrect as it does not actively involve the client in decision-making. Choice B acknowledges the client's feelings but does not directly engage them in the process. Choice D focuses on the client's responsibilities but does not promote active participation.
A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
- A. Instruct the client to avoid eating raw vegetables.
- B. Remind the client of the importance of medication adherence.
- C. Tell the client to avoid places where there are large crowds of people.
- D. Initiate a referral for the client to a home health agency.
Correct Answer: B
Rationale: Correct Answer: B. Remind the client of the importance of medication adherence.
Rationale: Ensuring medication adherence is crucial for managing AIDS. By reminding the client of this, the nurse advocates for the client's health and well-being. This action promotes the client's self-care and disease management, ultimately empowering the client to take control of their health.
Summary of other choices:
A: Instructing the client to avoid eating raw vegetables is not directly related to client advocacy in the context of AIDS management.
C: Telling the client to avoid large crowds does not directly address the client's ability to continue self-care at home.
D: Initiating a referral to a home health agency may be helpful but does not directly demonstrate client advocacy in this scenario.
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I will limit my portions of meat to 8 ounces.
- B. I will increase my intake of canned vegetables.
- C. I will use canola oil when making salad dressing.
- D. I will drink whole milk with my cereal.
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats. Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake. Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health. Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.