Nokea
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
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A nurse caring for a client with a new prescription checks the electronic database for medication information. Which component of critical thinking is the nurse using?
- A. Knowledge
- B. Experience
- C. Intuition
- D. Competence
Correct Answer: A
Rationale: The correct answer is A: Knowledge. Checking the electronic database for medication information involves accessing and utilizing factual information and data, which is a key component of knowledge in critical thinking. This process requires the nurse to gather relevant information, analyze it, and apply it to make informed decisions. Experience (B) and competence (D) are related to skills and proficiency but do not specifically focus on accessing information. Intuition (C) involves a gut feeling or instinct, which is different from actively seeking and using information.
Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.)
- A. Do you eat alone or with someone?
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A,C,D,E
Rationale: The correct answers are A, C, D, and E.
A: Asking if the person eats alone or with someone helps to assess social factors influencing eating habits, such as loneliness or lack of social interaction affecting appetite.
C: Inquiring about new medications can reveal potential side effects like appetite changes, nausea, or malabsorption leading to weight loss.
D: Knowing the foods consumed in the past 24 hours helps identify dietary patterns that may contribute to weight loss, such as poor nutrition or reduced intake.
E: Asking about a fixed income can uncover financial constraints affecting food choices and access to nutritious meals, potentially leading to weight loss.
Summary:
B: Watching TV while eating is not directly related to weight loss causes.
F and G: Not provided in the question, so no basis to consider them as relevant questions for investigating weight loss.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: The correct answer is C: Blood pressure cuff. To assess for orthostatic hypotension, the nurse needs to measure the patient's blood pressure in different positions - lying down, sitting, and standing. This is done using a blood pressure cuff to monitor any significant drop in blood pressure upon changing positions. A thermometer (choice A) is used to measure temperature and is not relevant to assessing orthostatic hypotension. Elastic stockings (choice B) are used for compression therapy in conditions like venous insufficiency and do not help in assessing orthostatic hypotension. Sequential compression devices (choice D) are used for preventing deep vein thrombosis and improving circulation, not for assessing orthostatic hypotension.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. This position, known as orthopneic position, helps improve breathing by allowing the chest to expand fully, making it easier to take deep breaths. Sitting on the side of the bed and resting arms over pillows on a raised table helps to reduce the work of breathing.
A: Lie on my back with head & shoulders elevated on a pillow - This position may not provide as much relief in breathing as the orthopneic position.
B: Lie flat on my stomach with head to one side - This position can actually make breathing more difficult for someone with COPD.
D: Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me - This position may not be as effective in improving breathing compared to the orthopneic position.
By choosing option C, the client can effectively manage breathing difficulties associated with
Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The description of linear clusters of fluid-containing vesicles with some crusting is characteristic of herpes zoster, also known as shingles. This condition is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature of herpes zoster. Allergic reaction (A) typically presents with generalized rash and itching, not linear clusters of vesicles. Ringworm (B) presents as circular, scaly lesions, not linear clusters of vesicles. Systemic lupus erythematosus (C) is an autoimmune disease that presents with a variety of symptoms, but not linear clusters of vesicles.