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The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?
- A. I will stop taking the medication if I experience dizziness.
- B. I will monitor my blood pressure regularly.
- C. I will avoid drinking alcohol while taking this medication.
- D. I will rise slowly from a sitting to a standing position.
Correct Answer: A
Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.
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A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?
- A. "I am struggling to accept that my parents are aging and need so much help."
- B. "It's been so stressful for me to think about having intimate relationships."
- C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish."
- D. "I love my grandchildren, but my child expects me to relive my parenting days."
Correct Answer: A
Rationale: The correct answer is A. The statement about struggling with aging parents indicates a significant stressor that could impact overall well-being and warrants further assessment. This statement reveals a potential source of emotional distress and adjustment difficulties for the client, as aging parents needing help can be a complex issue involving feelings of loss, role reversal, and increased responsibilities. Choices B, C, and D, although important, do not signify as immediate a need for further assessment compared to the challenges related to aging parents. Choice B focuses on intimate relationships, which is a common concern but may not be as urgent as dealing with aging parents. Choice C reflects feelings of selfishness but does not indicate an immediate need for further assessment. Choice D involves expectations from the client's child but does not highlight a critical issue that could impact the client's well-being as directly as struggling with aging parents.
The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?
- A. Apply a hydrocolloid dressing to the ulcer.
- B. Reposition the client every 2 hours.
- C. Use a donut-shaped cushion when the client is sitting.
- D. Massage the area around the ulcer to promote circulation.
Correct Answer: B
Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.
When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?
- A. SBAR
- B. SOAP
- C. PIE
- D. DAR
Correct Answer: A
Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.
A guardian reports that a 4-year-old child is waking up with nightmares. Which of the following interventions should the nurse suggest?
- A. Offer the child a large snack before bedtime.
- B. Allow the child to watch an extra 30 minutes of TV in the evening.
- C. Have the child go to bed at a consistent time every day.
- D. Increase physical activity before bedtime.
Correct Answer: C
Rationale: The correct answer is to have the child go to bed at a consistent time every day. Consistent bedtime routines can help reduce nightmares by providing the child with a sense of security and stability. Offering a large snack before bedtime or allowing extra TV time may disrupt sleep patterns and lead to nightmares. Increasing physical activity before bedtime could have the opposite effect and make it harder for the child to fall asleep.
A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
- A. Evaluate electrolytes
- B. Restrict fluid intake
- C. Administer diuretics
- D. Monitor vital signs
Correct Answer: A
Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.