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During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)
- A. Measure the client's blood pressure in both arms.
- B. Screen for a family history of diabetes mellitus.
- C. Arrange for immediate transport to a medical facility.
- D. Advise the client to restrict fluids and keep feet elevated.
- E. Discuss the importance of a regular exercise program.
Correct Answer: A,B,E
Rationale: Measuring blood pressure assesses hypertension risk, screening for diabetes history addresses increased risk from obesity, and discussing exercise helps manage obesity-related risks. Immediate transport is not indicated, and fluid restriction/elevation is irrelevant without edema.
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A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
- A. I just feel like my life is filled with emptiness.'
- B. I have three firearms locked in a safe at home.'
- C. My daughter is the only reason I keep trying.'
- D. My panic attacks happen once every month.'
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.
The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.
- A. Preoccupation.
- B. Reexperience.
- C. Somatization.
- D. Disorganization.
Correct Answer: C
Rationale: Somatization involves psychological distress manifesting as physical symptoms like numbness and tingling, likely due to grief. Other options are less applicable.
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?
- A. Spend time sitting in silence with the client.
- B. Involve the client in a daily exercise program.
- C. Ask the client to describe her depression.
- D. Observe for signs of possible psychosis.
Correct Answer: A
Rationale: Spending time in silence creates a supportive environment, allowing the client to communicate at her pace, addressing delayed responses.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?
- A. An adult with schizophrenia who often refuses to take prescribed antipsychotic medications.
- B. A hyperactive 4-year-old who has recently been tested for autism.
- C. An older adult resident of a long-term care facility who sometimes takes other residents' belongings.
- D. An adolescent who is depressed over not being accepted by peers.
Correct Answer: D
Rationale: Role-playing helps adolescents practice social skills and coping strategies for peer rejection, making it most effective for this group.