Nokea
An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?
- A. Giving the client a written exercise program.
- B. Explaining the exercise program to the client's spouse.
- C. Reassuring the client that he or she can do the exercise program.
- D. Tailoring a program to the client's needs and abilities.
Correct Answer: D
Rationale: Tailoring the exercise program to the client's needs and abilities ensures it is feasible and sustainable, promoting adherence.
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A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing?
- A. Inhale through the nose.
- B. Cough deeply from the lungs.
- C. Exhale through pursed lips.
- D. Splint the incisional site.
Correct Answer: D,A,C,B
Rationale: The correct order is: splint the incision (D) to reduce pain, inhale through the nose (A) to expand lungs, exhale through pursed lips (C) to control breathing, and cough deeply (B) to clear secretions.
A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:
- A. Position the client on a firm mattress
- B. Keep the involved extremity warm with blankets
- C. Position the left leg at or below the body's horizontal plane
- D. Encourage the client to raise and lower his leg four times every hour
Correct Answer: C
Rationale: Positioning the left leg at or below the body's horizontal plane promotes arterial blood flow to the extremity in arteriosclerosis, avoiding gravitational resistance. A firm mattress is irrelevant, warmth is beneficial but secondary, and leg raises may not be feasible pre-revascularization.
A female receiving radiation therapy for lung cancer complains to the nurse that she is having difficulty sleeping. Which of the following nursing actions is most appropriate?
- A. Suggest the client stop watching television before bed.
- B. Assess the client's usual sleep patterns, amount of sleep, and bedtime rituals.
- C. Tell the client sleeplessness is expected with radiation therapy.
- D. Suggest that the client stop drinking coffee until the therapy is completed.
Correct Answer: B
Rationale: Assessing sleep patterns, amount of sleep, and bedtime rituals provides a comprehensive understanding of the client's insomnia, enabling tailored interventions.
When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are:
- A. The effects of thyroid hormone replacement therapy and will diminish over time.
- B. Related to thyroid hormone replacement therapy and will not diminish over time.
- C. A normal part of having a chronic illness.
- D. Most likely related to low thyroid hormone levels and will improve with treatment.
Correct Answer: D
Rationale: Low thyroid hormone levels in hypothyroidism can cause depression and sadness, which typically improve with thyroid hormone replacement therapy.
An 82-year-old female has several ecchymotic areas on her left arm. The nurse should further assess the client for:
- A. Elder abuse.
- B. Self-inflicted injury.
- C. Increased capillary fragility and permeability.
- D. Increased blood supply to the skin.
Correct Answer: C
Rationale: Aging increases capillary fragility and permeability, leading to easy bruising (ecchymosis). While elder abuse is possible, capillary fragility is the most likely cause in this context.