Nokea
Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
- A. Introduce the client to other people who are successfully managing their care.
- B. Include the client's daughter in the teaching so that she can help implement the plan.
- C. Ask the client to identify other situations in which he demonstrated responsibility for himself.
- D. Reassure client that he will be able to implement all aspects of the plan successfully.
Correct Answer: C
Rationale: Encouraging the client to identify past instances of responsibility promotes self-efficacy and motivates self-care behaviors, which is most effective for long-term management.
You may also like to solve these questions
A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the following diseases can be transmitted by a designated donor? Select all that apply.
- A. Epstein-Barr virus.
- B. Human immunodeficiency virus (HIV).
- C. Cytomegalovirus (CMV).
- D. Hepatitis A.
- E. Malaria.
Correct Answer: B,C,E
Rationale: Blood transfusions, even from designated donors, carry a risk of transmitting certain diseases. HIV, CMV, and malaria are known to be transmissible through blood transfusions if the donor is infected, as these pathogens can persist in blood. Epstein-Barr virus is less commonly associated with transfusion transmission, and hepatitis A is primarily transmitted via the fecal-oral route, not blood. The nurse should inform the client of the risks of HIV, CMV, and malaria.
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action?
- A. Activate the rapid response team.
- B. Assess the client's orientation and vital signs.
- C. Administer a bolus of lidocaine.
- D. Notify the physician.
Correct Answer: B
Rationale: PVCs every other beat (bigeminy) may indicate serious irritability. Assessing orientation and vital signs first determines the client's stability, guiding further actions.
A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium (Sodium Pentothal) because this drug causes:
- A. Bradycardia.
- B. Complete muscle relaxation.
- C. Hypotension.
- D. Tachypnea.
Correct Answer: C
Rationale: Thiopental can cause hypotension, which is particularly risky in clients with impaired cardiac function, as it may exacerbate cardiovascular instability during induction.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs?
- A. Egg yolks.
- B. Brown rice.
- C. Vegetables.
- D. Tea.
Correct Answer: A
Rationale: Microcytic anemia is often due to iron deficiency. Egg yolks are a good source of iron, particularly heme iron, which is highly bioavailable. Brown rice and vegetables contain non-heme iron but in lower amounts, and tea inhibits iron absorption due to tannins. Egg yolks are the best choice.