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A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
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A provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?
- A. Increased muscle strength and tone to reduce muscle wasting
- B. Muscle hypertrophy to compensate for decreased joint strength
- C. Promotion of venous stasis to reduce the risk of embolus formation
- D. Reduction in bone density loss to prevent osteoporosis
Correct Answer: A
Rationale: The correct answer is A: Increased muscle strength and tone to reduce muscle wasting. Isometric exercises involve muscle contraction without joint movement, which helps improve muscle strength and tone. This is crucial in preventing muscle wasting commonly seen in clients with knee injuries. Muscle hypertrophy (B) is more associated with resistance training, not isometric exercises. Promotion of venous stasis (C) is incorrect as isometric exercises actually promote circulation and reduce the risk of blood clots. Reduction in bone density loss (D) is not directly related to isometric exercises.
A nurse is caring for a client who is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.
- A. Aromatherapy
- B. Biofeedback
- C. Guided imagery
- D. Yoga
Correct Answer: A
Rationale: Aromatherapy uses essential oils from plants to promote relaxation, improve mood, and support immune function.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress note
Correct Answer: A
Rationale: The correct answer is A: Client concerns. This is because the client themselves is the primary source of information about their own health and well-being. By directly listening to the client's concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but is secondary to the client's own input. Medical history (C) is important but may not always reflect the current situation. Progress notes (D) are valuable but are based on observations and interpretations by healthcare providers. Therefore, relying on the client's concerns ensures the most accurate and up-to-date information for the admission process.
A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse-client relationship?
- A. Telephones the client at his home prior to admission to make an introduction.
- B. Dominate the conversation to reduce the client's anxiety.
- C. Share stories about personal experiences with the client.
- D. Use active listening when with the client.
Correct Answer: D
Rationale: Using active listening helps establish presence by showing genuine interest and attention to the client.
A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?
- A. Use medical aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply petroleum jelly to the peristomal skin.
Correct Answer: C
Rationale: Securing new tracheostomy ties before removing old ones prevents accidental displacement. Medical asepsis is insufficient; sterile technique is required.