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A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching?
- A. I already had my immunizations as a child, so I'm protected in that area.'
- B. It is important to schedule routine health care visits even if I'm feeling well.'
- C. If I'm having any discomfort, I'll just go to an urgent care center.'
- D. If I am feeling stressed, I will remind myself that this is something I should expect.'
Correct Answer: B
Rationale: The correct answer is B: It is important to schedule routine health care visits even if I'm feeling well. This statement indicates an understanding of health promotion and illness prevention as it emphasizes the significance of preventive care to maintain overall health. Regular check-ups can help detect potential issues early on.
Incorrect choices:
A: I already had my immunizations as a child, so I'm protected in that area.
- This statement shows a misunderstanding of the need for ongoing preventive measures beyond childhood immunizations.
C: If I'm having any discomfort, I'll just go to an urgent care center.
- This statement reflects a reactive approach rather than a proactive one towards health.
D: If I am feeling stressed, I will remind myself that this is something I should expect.
- This statement does not address health promotion or illness prevention strategies.
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A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by:
- A. Asking what precipitates the pain
- B. Questioning the client about the location of the pain
- C. Offering the client a pain scale to measure his pain
- D. Using open-ended questions to identify the situation
Correct Answer: C
Rationale: The correct answer is C: Offering the client a pain scale to measure his pain. This is the best way to assess the intensity of the client's pain objectively. Pain scales provide a standardized way for clients to communicate their pain levels, allowing for more accurate assessment and monitoring. Asking what precipitates the pain (choice A) focuses on triggers, not intensity. Questioning about the location of pain (choice B) is important but doesn't directly measure intensity. Using open-ended questions (choice D) may not provide a quantitative measure of pain.
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all.
- A. Review a signal the client can use if feeling any distress.
- B. Lay a towel across the client's chest.
- C. Administer oral pain meds.
- D. Obtain a Dobhoff tube for insertion.
- E. Have a petroleum-based lubricant available.
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: Review a signal the client can use if feeling any distress - This is important to ensure the client can communicate any discomfort or issues during the procedure.
B: Lay a towel across the client's chest - Helps protect the client's clothing and bedding from potential spillage during the procedure.
C: Administer oral pain meds - Not necessary prior to NG tube insertion for gastric decompression.
D: Obtain a Dobhoff tube for insertion - Dobhoff tube is not typically used for gastric decompression with NG tube.
E: Have a petroleum-based lubricant available - Lubricant is required for NG tube insertion but not specifically petroleum-based.
F:
G:
Summary: Choices C, D, and E are not necessary prior to beginning the NG tube insertion procedure. Choice A and B are essential steps to ensure patient safety and comfort during the process.
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
- E. Rosenbaum test
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and heel-to-toe walk. The Romberg test evaluates proprioception and balance by having the client stand with feet together and eyes closed. If the client sways, it indicates balance impairment. The heel-to-toe walk assesses gait and balance by asking the client to walk in a straight line placing the heel of one foot in front of the toes of the other foot. Choices C, D, and E are incorrect as they are not related to balance assessment. The Snellen test evaluates visual acuity, spinal accessory function assesses shoulder movement, and Rosenbaum test measures near vision acuity.