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The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
- A. To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue.
- B. To cover the bony prominence and areas where there is skin breakdown.
- C. So the client knows what type of clothing to wear when weighed.
- D. To reduce the tendency of the client to hide objects under his or her clothing.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?
- A. I will use my peak flow meter every morning.
- B. I will use my peak flow meter when I feel short of breath.
- C. I will use my peak flow meter before using my inhaler.
- D. I will use my peak flow meter after using my inhaler.
Correct Answer: A
Rationale: The correct answer is A because using the peak flow meter every morning provides a baseline measurement of lung function when the client is typically stable. This allows for early detection of changes and adjustment of treatment. Choice B is incorrect as waiting until feeling short of breath may be too late. Choice C is incorrect because using the peak flow meter before the inhaler may not provide an accurate measurement. Choice D is incorrect as using the peak flow meter after the inhaler may not reflect the true lung function.
A client who is interested in smoking cessation receives teaching from a nurse. Which statements should the nurse include in this teaching? (Select ONE that does not apply)
- A. Find an activity that you enjoy and that will keep your hands busy.
- B. Keep healthy snacks on hand to nibble on.
- C. Identify reasons for quitting smoking.
- D. Make a list of reasons for quitting smoking.
Correct Answer: C
Rationale: The correct answer is C: Identify reasons for quitting smoking. This should not be included in the teaching because the client should already have identified their reasons for quitting before receiving the teaching. The client should have a clear understanding of why they want to quit smoking before seeking help. Choices A and B are correct as they provide practical tips to distract from smoking and avoid unhealthy behaviors. Choice D is also correct as making a list of reasons can help reinforce motivation.
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
- A. 100% of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct Answer: B
Rationale: The correct answer is B because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation.
A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy.
C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy.
D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.
A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?
- A. Fremitus
- B. Hyperresonance
- C. Dullness on percussion
- D. Decreased tactile fremitus
Correct Answer: C
Rationale: The correct answer is C: Dullness on percussion. Pneumonia is characterized by consolidation of lung tissue, causing dullness on percussion due to increased density. Fremitus (A) and tactile fremitus (D) are decreased in conditions like pleural effusion or pneumothorax, not pneumonia. Hyperresonance (B) is associated with conditions like emphysema, not pneumonia. In pneumonia, the affected area is consolidated, leading to dullness on percussion.
What aspect should a nurse pay particular attention to when assessing a client with a potential or actual infection?
- A. The client’s age and sex
- B. The client’s lifestyle and drinking habits
- C. The client’s recent travel to a foreign country
- D. The client’s diet and preference for meat
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.