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The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
- A. Encourage the client's family to visit more often
- B. Schedule a daily conference with the social worker
- C. Encourage the client to participate in group activities
- D. Engage the client in a non-threatening conversation
Correct Answer: D
Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.
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The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?
- A. "I will use lemon juice and herbs for flavoring."
- B. "I will not eat canned soups or frozen dinners."
- C. "I can have salt substitutes to enhance the taste of my food."
- D. "I will check the food labels for sodium content before buying."
Correct Answer: C
Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.
A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?
- A. When you kiss her, does she taste salty?
- B. Do you notice if her urine has a musty odor?
- C. Has she been drinking cow's milk in her daily diet?
- D. How often does she have a normal bowel movement?
Correct Answer: A
Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF. Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.
A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Anxiety related to treatment plan
- B. Deficient knowledge of lifestyle changes
- C. Ineffective coping related to denial
- D. Decisional conflict due to stress
Correct Answer: C
Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.
A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor urine output hourly
- B. Assess for back muscle aches
- C. Record drainage from the drain
- D. Obtain body weight daily
Correct Answer: C
Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.
The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?
- A. Assess for signs of lymphedema
- B. Encourage the client to perform arm exercises
- C. Provide pain relief through medication
- D. Recommend wearing a compression sleeve
Correct Answer: A
Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.