Nokea
In conducting a community health fair for a group of middle-aged citizens, which statement should the nurse emphasize in reducing the risk of coronary heart disease?
- A. Participate in at least 30 minutes of moderate physical activity 3 to 5 days per week.
- B. Engage in an aerobic exercise class every day.
- C. Limit your alcohol intake to a moderate level.
- D. The best way to lose weight is to follow a balanced diet.
Correct Answer: B
Rationale: Engaging in an aerobic exercise class every day is crucial in reducing the risk of coronary heart disease. Aerobic exercises help keep the heart in shape, lower blood pressure, and improve cholesterol levels. It is recommended to participate in at least 150 minutes of moderate-intensity aerobic exercise per week, which can be achieved by engaging in aerobic exercise daily. Choice A has been corrected to emphasize the frequency required to significantly reduce the risk of coronary heart disease. Choice C has been modified to suggest moderation in alcohol intake, as excessive alcohol consumption is harmful. Choice D is also incorrect as a balanced diet, not specifically high-protein, high-fat, is recommended to reduce the risk of coronary heart disease and maintain a healthy weight.
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The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:
- A. Fearful situations
- B. Depression
- C. Delusions
- D. Anxiety
Correct Answer: D
Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts. Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself. Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression. Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.
Which of the following individuals is at the highest risk for suicide?
- A. 76-year-old widow with chronic renal failure
- B. 19-year-old with new SSRI therapy
- C. 28-year-old post-partum crying weekly
- D. 50-year-old client with obsessive-compulsive disorder (OCD) and depression
Correct Answer: A
Rationale: The correct answer is the 76-year-old widow with chronic renal failure. Elderly individuals with chronic diseases, especially men, are at very high risk for suicide. The other choices, although they may be vulnerable populations, do not carry as high a risk for suicide. The 19-year-old with new SSRI therapy may actually have a lower risk as they are receiving treatment. The 28-year-old post-partum individual is experiencing a common emotional response after childbirth, which is not necessarily indicative of a high suicide risk. The 50-year-old with OCD and depression is at risk but not as high as elderly individuals with chronic illness.
Which task would be appropriate for the LPN to perform?
- A. Changing a colostomy bag.
- B. Hanging a new bag of TPN.
- C. Drawing a peak antibiotic blood level from a central line.
- D. Administering IV pain medication to a two-day post-op client.
Correct Answer: A
Rationale: The correct answer is changing a colostomy bag. This task falls within the LPN's scope of practice. LPNs are trained to provide basic nursing care, including assisting with activities of daily living and certain medical procedures like changing ostomy bags. Hanging a new bag of TPN and drawing a peak antibiotic blood level from a central line are tasks that require a higher level of training and are typically performed by RNs due to their complexity and potential risks. Administering IV pain medication to a two-day post-op client is usually the responsibility of an RN as it involves close monitoring, assessment of the client's condition, and the administration of potent medications that require a higher level of clinical judgment and expertise.
The client is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?
- A. Allow the client to honestly discuss her fears and encourage her to talk more with her physician.
- B. Tell her the good things that she will be able to do without more children and encourage her to make a list of positive things.
- C. Explain to the client that her ovaries can be frozen for egg harvesting at a later time and she can find a surrogate.
- D. Advise the client to put off having the surgery until she is sure that she wants to undergo the procedure and notify the surgeon of the decision.
Correct Answer: A
Rationale: In this situation, the most appropriate action for the nurse is to allow the client to express her fears and concerns openly. By encouraging her to talk more with her physician, the nurse is promoting effective communication and ensuring that the client receives adequate information to make an informed decision. Option A is correct because it acknowledges the client's emotions and empowers her to seek clarification and support from her healthcare provider. Options B and C do not address the client's emotional needs or provide a solution to her concerns regarding fertility. Option D is not appropriate as it does not prioritize the client's emotional well-being and delays necessary medical treatment for advanced cervical cancer.
Which action by a graduate nurse would require the charge nurse to intervene?
- A. Walking in the hallway outside the operating room without a hair covering
- B. Putting on a surgical mask, gown, and cap before entering the operating room
- C. Wearing a surgical mask into the holding area
- D. Wearing scrubs from home into the nursing station
Correct Answer: A
Rationale: The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse. Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control. Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.