Nokea
A nurse is providing discharge teaching to a client following a right mastectomy. Which of the following statements should indicate to the nurse that the client has a healthy body image?
- A. Do I have to go home with drains?
- B. The incision looks like it is healing.
- C. My sister will change the dressing every day.
- D. When will all this pain start to go away?
Correct Answer: B
Rationale: A statement acknowledging the healing process suggests the client is adjusting positively to body image changes.
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A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, 'I'm afraid of what's going to happen.' Which of the following responses should the nurse make?
- A. Assure the client that the surgery is safe and complications are rare.
- B. Encourage the client to discuss her fears further.
- C. Inform the client that she has an excellent provider and has nothing to worry about.
- D. Explain to the client that anxiety can prolong hospitalization.
Correct Answer: B
Rationale: Encouraging the client to talk about their fears provides emotional support and can reduce anxiety.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.
A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?
- A. Reiki
- B. Aromatherapy
- C. Acupuncture
- D. Yoga
Correct Answer: D
Rationale: Yoga combines physical postures, breathing exercises, and meditation to reduce stress and promote well-being.
A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with the client? (Select all that apply.)
- A. Materials should be culturally diverse.
- B. Information must be accurate and current.
- C. Materials should be written at the eighth-grade level.
- D. Materials should be written in the client's spoken language.
- E. Materials should be distributed to the client in advance.
Correct Answer: A,B,C,D
Rationale: The correct tools for teaching a client with heart failure should include: A) Culturally diverse materials to ensure relevance and understanding across different backgrounds; B) Accurate and current information to provide the client with up-to-date knowledge for managing their condition effectively; C) Materials written at an eighth-grade level to ensure clarity and ease of comprehension; D) Materials in the client's spoken language to facilitate understanding and communication. These tools are essential for effective patient education in heart failure management. Other choices are incorrect as they may not address the client's specific needs or may hinder their understanding of the information.
A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
- A. Atelectasis
- B. Rales
- C. Rhonchi
- D. Pneumothorax
Correct Answer: A
Rationale: Atelectasis causes absent breath sounds in lung bases due to alveolar collapse.