Nokea
The nurse is planning discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day.
Which of the following recommendations by the nurse would be BEST?
- A. Participation in a program such as 'Nicotine Avoidance.'
- B. Avoidance of aerobic physical activity.
- C. Instillation of a humidifier in the home heating system.
- D. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet
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The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.
The nurse is caring for a client who is suffering from severe anxiety. What must the client do first when learning to deal with his anxiety?
- A. Recognize that he is feeling anxious
- B. Identify the situations that precipitated his anxiety
- C. Understand the reason for his anxiety
- D. Select a strategy to use to help him cope with his anxiety
Correct Answer: A
Rationale: Recognizing anxiety is the first step in managing it, enabling the client to address triggers, reasons, and coping strategies sequentially.
All of the following clients need care. Who should the nurse see first?
- A. A diabetic whose blood sugar is 40
- B. A postoperative client who is complaining of severe pain
- C. A person with terminal cancer who is complaining of pain
- D. A client with an indwelling catheter who is complaining of bladder pain
Correct Answer: A
Rationale: A blood sugar of 40 indicates severe hypoglycemia, a life-threatening emergency requiring immediate intervention. Pain complaints are less urgent.
A nursing assistant is assigned to constant observation of a suicidal patient.
Which of the following statements made by the nursing assistant would require IMMEDIATE intervention by the nurse?
- A. Let's put your clothes in the dresser.'
- B. I'll stay in the bathroom with you while you take your shower.'
- C. You're going to be moved to a private room later today.'
- D. I'll be right back with something for you to eat.'
Correct Answer: D
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that something is wrong. (1) no reason to intervene (2) appropriate, client is not to be left alone for any reason (3) no reason to intervene (4) correct-client under constant observation; must not be left alone for any reason
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: Amenorrhea. Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.