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If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by:
- A. Explaining how the old behavior leads to poor health.
- B. Withholding praise until the new behavior is well established.
- C. Rewarding the client whenever the acceptable behavior is performed.
- D. Instilling mild fear into the client to extinguish the behavior.
Correct Answer: C
Rationale: Positive reinforcement, such as rewarding adaptive behaviors, encourages the client to continue healthy habits. Fear or delayed praise is less effective for behavior modification.
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The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.
The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................
- A. ¾-in, 25-gauge needle.
- B. into the middle third of the anterolateral aspect of the thigh.
- C. aspirate before injecting the medication.
- D. massage the area to promote medication absorption.
- E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
- F. lower conjunctival sac.
- G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F
Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following?
- A. Signs of skin pressure in the groin area.
- B. Evidence of decreased breath sounds.
- C. Skin breakdown behind the heel.
- D. Urine retention.
Correct Answer: A
Rationale: The Thomas splint can cause pressure in the groin, requiring regular skin assessments to prevent breakdown.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
The nurse is assessing a 60-year-old male who has hoarseness. The nurse should conduct a focused assessment to determine:
- A. Patterns of medication use and history of alcohol consumption.
- B. Exposure to sun and family history of head and neck cancers.
- C. Exposure to wood dust and a high-fat diet.
- D. History of tobacco use and alcohol consumption.
Correct Answer: D
Rationale: Hoarseness in a 60-year-old male is concerning for head and neck cancers, particularly laryngeal cancer. A focused assessment should prioritize tobacco and alcohol use, as these are major risk factors.
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
- A. Call the Post Anesthesia Care Unit (PACU).
- B. Call the primary care physician.
- C. Call the respiratory therapist.
- D. Call the Rapid Response Team.
Correct Answer: D
Rationale: Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.