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The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most important health promotion brochure to provide to an obese client newly diagnosed with arteriosclerosis is one focused on decreasing cholesterol levels through diet. Arteriosclerosis is significantly influenced by excess dietary fat, especially saturated fat and cholesterol. Monitoring blood pressure at home, while important, does not directly address the underlying cause of arteriosclerosis. Smoking cessation and stress management are crucial for overall cardiovascular health, but lowering cholesterol through diet takes precedence in this scenario.
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A mother states to the nurse, 'I am afraid that my child might have another febrile seizure.' Which therapeutic statement is best for the nurse to make to the mother?
- A. Tell me what frightens you the most about seizures.
- B. Tylenol can prevent another seizure from occurring.
- C. Most children will never experience a second seizure.
- D. Why worry about something that you cannot control?
Correct Answer: A
Rationale: Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct Answer: D
Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.
The nurse plans care for a client diagnosed with anorexia nervosa. Which goal will the nurse make a priority for this client?
- A. Gain one-fourth pound (0.11 kg) per week.
- B. Maintain potassium balance between 3.5 and 5.0 mEq/L (3.5 to 5.0 mmol/L).
- C. Eat 50% of each meal.
- D. Identify a normal weight for height.
Correct Answer: A
Rationale: Gradual weight gain (0.25 lb/week) is the priority goal for anorexia, addressing malnutrition and physical health risks. Electrolyte balance and meal consumption are important but secondary, and identifying normal weight is a long-term cognitive goal.
The nurse on the psychiatric unit notices that a client diagnosed with depression does not eat meals. Which response by the nurse is appropriate?
- A. Suggest the client take meals in the client's room.
- B. Ask the client to identify favorite foods.
- C. Offer the client high-calorie foods to carry around.
- D. Set a goal for percentage of meal consumption.
Correct Answer: B
Rationale: Asking the client to identify favorite foods engages them in their care and may increase appetite by incorporating preferences, addressing the underlying issue of poor intake. Other options may not address motivation or may impose goals without client input.
The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best?
- A. You have not done anything wrong. Your spouse is probably experiencing war memories.
- B. Do what is asked. Make the environment quiet and keep your distance until your spouse is less upset.
- C. Approach your spouse calmly and slowly, saying your name and current location.
- D. Touch your spouse's arm gently and ask what is causing the anger.
Correct Answer: B
Rationale: Respecting the veteran’s need for space by keeping the environment quiet and maintaining distance reduces stimulation and potential escalation, especially during possible PTSD episodes. Approaching or touching may increase agitation, and reassurance is less actionable.