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If the patient becomes discouraged during the rehabilitation program, what should the nurse do?
- A. Tell the family that the patient has not adjusted
- B. Stop the rehabilitative program until the patient is more optimistic
- C. Listen to his complaints and continue to encourage him
- D. Ignore his complaints and continue with the rehabilitation efforts
Correct Answer: C
Rationale: Active listening and encouragement help maintain motivation and adherence to the rehabilitation program.
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Which action occurs primarily during the evaluation phase of the nursing process?
- A. Data collection.
- B. Decision-making and judgment.
- C. Priority-setting and expected outcomes.
- D. Reassessment and audit.
Correct Answer: B
Rationale: Evaluation involves assessing whether goals were met and making judgments about care effectiveness.
A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?
- A. Serosanguineous drainage from the puncture site
- B. Discomfort at the puncture site
- C. Increased heart rate
- D. Decreased temperature
Correct Answer: C
Rationale: The correct answer is C, increased heart rate, as it indicates a potential complication such as hemorrhage or pneumothorax post-thoracentesis. An increased heart rate can signify hypovolemia or respiratory distress, requiring immediate provider notification. Serosanguineous drainage (A) is expected initially, discomfort (B) is common, and decreased temperature (D) is not typically a complication post-thoracentesis.
Why should the nurse closely monitor older adults when they are receiving IV therapy?
- A. Because their defense mechanisms are less efficient.
- B. Because they are prone to fluid overload.
- C. Because they are prone to increased renal efficiency.
- D. Because they have inadequate intake of dietary fiber.
Correct Answer: B
Rationale: The correct answer is B because older adults are more prone to fluid overload due to reduced kidney function.
Mary, who is diagnosed with osteomyelitis, may not heal properly unless she has
- A. Debridement and drainage of the area.
- B. Immobilization of the area.
- C. Ice packs alternating with moist heat, applied externally.
- D. Internal fixation device inserted.
Correct Answer: A
Rationale: Debridement and drainage are necessary to remove infected tissue and promote healing.
What does using random weights help to prevent when weighing a client diagnosed with binge eating?
- A. Dehydration
- B. Lying about weight
- C. Water loading
- D. Denial of weight loss
Correct Answer: B
Rationale: Random weights reduce opportunities for clients to manipulate or lie about their actual weight.