Nokea
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.
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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 home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client's pain?
- A. The client's pain rating
- B. The nurse's impression of the client's pain
- C. Verbal and nonverbal clues from the client
- D. Pain relief after appropriate nursing intervention
Correct Answer: A
Rationale: The client's perception of pain is the hallmark of pain assessment. Usually noted by the client's rating on a scale of 1 to 10, the assessment is documented and followed with appropriate medical and nursing interventions. The nurse's impression and the verbal and nonverbal clues are subjective data. Pain relief after intervention is appropriate but relates to evaluation.
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.
After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
- A. Ask the client to remain quiet so the procedure can be performed safely.
- B. Concentrate on completing the insertion as efficiently as possible.
- C. Calmly reassure the client that the discomfort will be temporary.
- D. Tell the client a joke as a means of distraction from the procedure.
Correct Answer: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should the nurse provide to ensure the optimal benefits from the drug?
- A. Fill your lungs with air through your mouth and then compress the inhaler.
- B. Compress the inhaler while slowly breathing in through your mouth.
- C. Compress the inhaler while inhaling quickly through your nose.
- D. Exhale completely after compressing the inhaler and then inhale.
Correct Answer: B
Rationale: To ensure optimal benefits from a metered-dose inhaler, the client should be instructed to compress the inhaler while slowly breathing in through the mouth. This technique facilitates the medication to reach deep into the lungs, allowing for an optimal bronchodilation effect. Option B is correct as it promotes the proper coordination of inhaler compression and inhalation, ensuring effective drug delivery. Options A, C, and D are incorrect as they do not support deep lung penetration of the medication, which is essential for its effectiveness in treating respiratory conditions.