Nokea
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
- A. Confirm that all staff members understand and comply with the treatment plan.
- B. Establish mutually agreed upon, realistic goals.
- C. Ensure that the potent reinforcers (rewards) are important to the client.
- D. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program
You may also like to solve these questions
The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should the nurse include?
- A. Avoid swimming or bathing alone.
- B. Take medications only when a seizure occurs.
- C. Drive a car as long as you feel alert.
- D. Consume alcohol in moderation to reduce stress.
Correct Answer: A
Rationale: avoiding swimming or bathing alone reduces the risk of injury during a seizure
The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?
- A. I should inhale through my mouth.'
- B. I should tighten my abdominal muscles with inhalation.'
- C. I should contract my abdominal muscles with exhalation.'
- D. I should make inhalation twice as long as exhalation.'
Correct Answer: C
Rationale: Pursed-lip breathing involves inhaling through the nose and exhaling slowly through pursed lips, which may involve contracting abdominal muscles to assist with exhalation, prolonging exhalation to reduce air trapping in COPD.
The nurse is working with an unlicensed assistive personnel (UAP). In planning the morning's care, which tasks can the nurse delegate to the UAP? Select all that apply.
- A. feeding a client who has lost the use of his hands
- B. starting an IV in a confused client who pulled her IV out
- C. assisting a stable and alert client up to the bedside commode
- D. checking an apical pulse in a client prior to administering digoxin
- E. ambulating a client in the hall for the first time since surgery to repair a fractured T5 vertebra
Correct Answer: A, C
Rationale: Feeding and assisting a stable client to the commode are within the UAP’s scope, while starting an IV, checking an apical pulse, and ambulating a post-surgical client require nursing judgment.
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself.
- B. She pulls a toy behind her.
- C. She can build a tower of eight blocks.
- D. She can copy a horizontal or vertical line.
Correct Answer: B
Rationale: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.
A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 cc in 2 hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?
- A. Furosemide (Lasix) IV push
- B. Irrigate the Foley catheter
- C. Increase the IV fluids to 200 mL/hr
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Signs of fluid overload (JVD, edema, low urine output, crackles) suggest the need for furosemide (Lasix) to reduce excess fluid and prevent pulmonary edema.