Nokea
The multidisciplinary team decides to implement behavior modification with a client.
- A. What is the primary nursing action during implementation of behavior modification?
- B. Confirm that all staff members understand and comply with the treatment plan.
- C. Establish mutually agreed upon, realistic goals.
- D. Ensure that the potent recorders (rewards) are important to the client.
- E. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: Consistency in applying the behavior modification plan is critical for success. Confirming that all staff members understand and comply ensures consistent implementation, reducing manipulation by the client or staff. While setting goals, choosing rewards, and scheduling reinforcement are important, they are secondary to ensuring staff alignment.
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A client comes to the emergency room with complaints of 'numbness, tingling, and coldness' of her left leg. She is able to walk. You note that the skin appears pale and is cool to the touch. What should the nurse do first?
- A. Ask if she had had a similar condition in her arms or the other leg
- B. Notify the physician immediately
- C. Obtain a detailed nursing health history
- D. Palpate and record the femoral, popliteal, posterior tibial, and dorsalis pedis pulses in the affected leg
Correct Answer: D
Rationale: Palpating pulses assesses for arterial occlusion, the priority to determine the cause of numbness and coldness, guiding urgent intervention.
A client is scheduled for a traditional abdominal cholecystectomy.
Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important?
- A. It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet.'
- B. Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times.'
- C. There will be a machine available to you after surgery for you to use to continuously receive pain medication.'
- D. You may come back from surgery with a tube in your nose that drains your gall bladder.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct-should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication is administered intermittently (4) NG tube used to drain stomach, T-tube used to drain common bile duct
The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?
- A. Take at least 2 weeks off from work.
- B. You will need another chest x-ray in 6 weeks.
- C. Take a longer temperature range of time.
- D. Complete all of the antibiotic even if your findings decrease.
Correct Answer: D
Rationale: Complete all of the antibiotic even if your findings decrease. Finishing the full antibiotic course prevents recurrence and resistance.
An adult is taking digoxin and furosemide. Which laboratory value is of greatest concern to the nurse?
- A. Serum digoxin of 1.2 ng/mL
- B. Serum K+ of 3.0 mEq/L
- C. BUN of 12 mg/dL
- D. Serum Mg of 1.6 mEq/L
Correct Answer: B
Rationale: Furosemide, a diuretic, can cause hypokalemia (low potassium), increasing the risk of digoxin toxicity. A serum K+ of 3.0 mEq/L is below normal (3.5-5.0 mEq/L), posing a significant risk. The digoxin level is therapeutic (0.5-2.0 ng/mL), and BUN and Mg are within normal ranges.
A client is admitted with a tentative diagnosis of bladder cancer. Which finding most likely contributed to the development of bladder cancer?
- A. Two PPD cigarette use for 25 years
- B. Frequent urinary tract infections
- C. Employment in the textile industry
- D. A history of renal calculi
Correct Answer: A
Rationale: Cigarette smoking is a significant risk factor for bladder cancer due to the exposure to carcinogenic chemicals excreted in urine. Answer A (two packs per day for 25 years) is the most likely contributor. Answers B, C, and D are less directly associated with bladder cancer development.