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The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?
- A. Limit sodium intake to 2,300 mg per day
- B. Engage in moderate exercise for 30 minutes daily
- C. Consume a diet high in saturated fats
- D. Avoid alcohol consumption completely
Correct Answer: B
Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.
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Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
- A. Perform cough and deep breathing exercises hourly.
- B. Turn from side to side in bed at least every 2 hours.
- C. Dorsiflex and plantarflex the feet 10 times each hour.
- D. Drink approximately 4 ounces of water every hour.
Correct Answer: C
Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
- A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
- B. Notify the healthcare provider and request a prescription for a large-volume enema.
- C. Assess the client's medical record to determine the client's normal bowel pattern.
- D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
Correct Answer: C
Rationale: When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.
The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct Answer: B
Rationale: To calculate the volume to administer, use the formula (1 mL 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.
A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?
- A. Encourage the student to associate with non-smokers only while attempting to stop smoking.
- B. Tell the student that he is still young and should continue trying various smoking cessation methods.
- C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness.
- D. Provide the student with the latest research data describing the long-term effects of tobacco use.
Correct Answer: A
Rationale: Adolescents are particularly influenced by peers, so associating with non-smokers may help the student quit smoking. By being surrounded by non-smokers, the student is less likely to feel pressured to smoke and may be encouraged to adopt healthier behaviors. This intervention leverages the power of social influence to support smoking cessation efforts and create a more conducive environment for the student to quit smoking. Choices B, C, and D do not address the social aspect of smoking behavior and the influence of peers on smoking habits, making them less effective interventions in this case.
When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?
- A. Divert the client's attention
- B. Call for additional help from staff
- C. Document the planned action
- D. Re-assess the client's situation
Correct Answer: D
Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client's attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.