Nokea
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
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Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I'm struggling to accept my parents are aging & 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 good cause, but maybe I'm just selfish
- D. I love my grandchildren, but my son expects me to relive my parenting days
Correct Answer: B
Rationale: The correct answer is B: It's been so stressful for me to think about having intimate relationships. This issue should be prioritized for more assessment and intervention because difficulties with intimate relationships can significantly impact one's mental and emotional well-being. It may indicate underlying issues such as fear of intimacy, past trauma, or self-esteem issues. Addressing these issues can help improve overall quality of life.
Choice A is not the priority as accepting aging parents is a common life transition and may not have an immediate negative impact on mental health. Choice C, feeling selfish for not volunteering, is important but may not be as urgent as addressing intimate relationship stress. Choice D, feeling pressured by son about grandparenting, is important but may not directly affect the individual's mental well-being.
Nurse performing an admission assessment for older adult client. After gathering assessment data & performing review of systems
- A. which of following actions is priority for nursing?
- B. Orient client to his room
- C. Conduct client care conference
- D. Review client's medical orders
- E. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A - which of the following actions is a priority for nursing? The rationale is as follows: Priority should be given to addressing any urgent needs or potential risks to the client's health and safety. In this scenario, conducting a thorough assessment to identify any immediate health concerns or issues is crucial before proceeding with other actions. By prioritizing assessment, the nurse can ensure that any critical conditions are promptly identified and addressed, leading to better outcomes for the older adult client. Other choices are incorrect because orienting the client to the room, conducting a care conference, reviewing medical orders, and developing a plan of care are important tasks but should come after the initial assessment to establish a baseline for care.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?
- A. Prevention of atelectasis
- B. Prevention of renal calculi
- C. Prevention of pressure ulcers
- D. Prevention of joint contractures
Correct Answer: D
Rationale: The correct answer is D, prevention of joint contractures. Passive ROM and splinting help maintain joint flexibility and prevent contractures in immobile patients. Contractures are abnormal shortening of muscles causing joints to remain in fixed positions. Preventing joint contractures is essential for preserving mobility.
A: Prevention of atelectasis is unrelated to passive ROM and splinting.
B: Prevention of renal calculi is not a direct outcome of passive ROM and splinting.
C: Prevention of pressure ulcers is important but not directly related to joint mobility.
In summary, the goal of the nurse's action is to prevent joint contractures, as immobility can lead to loss of joint motion.
Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial because removing the chemical from the skin and clothing helps prevent further exposure and damage. Irrigating the affected area with running water (choice A) may spread the chemical and worsen the burn. Washing with antibacterial soap (choice B) is not recommended for chemical burns. Applying a neutralizing agent (choice D) can be harmful if the chemical is unknown. The key is to remove the chemical by brushing it off to minimize skin contact and reduce the risk of absorption.
When entering client's room to change dressing
- A. nurse notes client is coughing & sneezing. When preparing sterile field
- B. it's important the nurse...
- C. Keep sterile field at least 6 ft away from client's bedside
- D. Instruct client to not cough/sneeze during dressing change
- E. Place mask on client to limit spread of microorganisms into surgical wound
Correct Answer: C
Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.