Nokea
The practical nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy would be most effective to reinforce prior teaching from the registered nurse?
- A. Leave diet pamphlets for the client to review at a later time
- B. Refer the client to the nurse case manager to follow up with diet instructions
- C. Sit with the client during meal selections and assist with identification of low sodium options
- D. Turn the television on in the client's room to the patient education channel to watch
Correct Answer: C
Rationale: Active participation in meal selection reinforces learning and promotes adherence to a low-sodium diet.
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A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?
- A. Increase intake of meats, eggs, fish, plums, and cranberries.
- B. Avoid citrus fruits and juices.
- C. Avoid dark green, leafy vegetables.
- D. Increase intake of dairy products.
Correct Answer: C
Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.
The nurse finds a person unresponsive on the floor. What is the initial nursing action?
- A. Start chest compressions
- B. Assess respirations and pulse
- C. Place on a hard surface
- D. Start mouth-to-mouth breathing
Correct Answer: B
Rationale: Assessing respirations and pulse determines if CPR is needed, per ACLS guidelines. Compressions, positioning, or breathing are premature without confirming unresponsiveness and absence of pulse/breathing.
The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, 'It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore.' Which response by the nurse is best?
- A. Perhaps finding a caregiver to care for your spouse at night might be helpful.
- B. Tell me about the care you provide in a typical day and its challenges.
- C. Try not to worry. It's normal to feel overwhelmed when you are stressed.
- D. You seem worried that you won't be able to provide the care that your spouse needs.
Correct Answer: B
Rationale: Exploring the spouse's daily challenges encourages open communication and helps identify specific support needs.
The nurse is talking with a client whose spouse recently attempted suicide. The client states, 'If I had not intervened, my spouse would have died. I cannot believe this is happening.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do not focus on the negative. You should try to focus on helping your spouse get better.
- B. I imagine that this is overwhelming. Tell me more about how you are feeling right now.
- C. Do you have any relatives or close friends who can help support you through this?
- D. Has your spouse been experiencing worsening depression recently?
Correct Answer: B
Rationale: Acknowledging the client's feelings and encouraging expression provides emotional support.
Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.
- A. Exercise programs
- B. Good room lighting
- C. Handrails in stairwell
- D. Smooth-soled shoes
- E. Staff hourly rounds
Correct Answer: A,B,C,E
Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.