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The nurse is reinforcing discharge teaching for a client who has a low health literacy level. Which of the following actions should the nurse take? Select all that apply.
- A. Provide as much detail as possible.
- B. Utilize the teach-back method.
- C. Repeat important information.
- D. Use visual aids.
- E. Speak loudly.
Correct Answer: B,C,D
Rationale: Teach-back confirms understanding, repeating key points reinforces learning, and visual aids simplify concepts. Excessive detail overwhelms low-literacy clients, and loud speech is unnecessary unless hearing-impaired.
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The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.
- A. often sleeps during class or after-school activities
- B. has received disciplinary action at school due to absenteeism and angry outbursts
- C. has unintentionally lost 8 lb (3.6 kg) over the past 3 weeks
- D. abruptly quit playing sports despite receiving previous athletic awards and trophies
- E. voices concern about the appearance of acne on the face
Correct Answer: A,B,C,D
Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.
The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.
- A. Encourage the client to speak slowly and pause to take deep breaths periodically
- B. Identify and promote the client's capabilities and strengths throughout the sessions
- C. Provide client teaching during times of day when the client has the most energy
- D. Reserve discussion of important or complex teaching for the client's caregiver
- E. Schedule teaching sessions at times with low risk of rushing or interruptions
Correct Answer: A,B,C,E
Rationale: Speaking slowly aids clarity, promoting strengths builds confidence, teaching during high-energy times optimizes learning, and uninterrupted sessions enhance focus. Complex teaching should include the client, not just the caregiver, to respect autonomy.
A client with schizophrenia is ready to begin participating in therapeutic activities. The nurse should suggest that the client:
- A. Participate on the unit softball team
- B. Attend a class on psychotropic medication
- C. Participate in art activities with three other clients
- D. Watch TV in the unit day room
Correct Answer: C
Rationale: Art activities with a small group provide a structured, low-stress environment suitable for a client with schizophrenia, promoting social interaction without overwhelming them.
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
- A. Teach the parents how to perform cardiopulmonary resuscitation
- B. Recommend that the parents give in when he holds his breath to prevent anoxia
- C. Advise the parents to ignore breath holding because breathing will begin as a reflex
- D. Instruct the parents on how to reason with the child about possible harmful effects
Correct Answer: C
Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.