Nokea
During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down.
Which of the following statements by the nurse is BEST?
- A. What is the weather like outside?
- B. Do you not want to talk with me today?
- C. Are you cold sitting here?
- D. You seem to be feeling sad today.
Correct Answer: D
Rationale: Strategy: 'BEST' indicates that this is a priority question. Remember therapeutic communication. (1) is used to get client comfortable, but would not help to focus on what is important (2) focusing on client's difficulty speaking may make him defensive and block communication (3) concrete questions will encourage client to give yes/no answers, factual answers may block communication of feelings (4) correct-reflection allows client to verbalize feelings
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The nurse in the outpatient clinic plans care for a 65-year-old woman with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to
- A. increase the amount of calcium in her daily diet.
- B. increase the amount of vitamin D in her daily diet.
- C. increase the amount of time she is exposed to sunlight.
- D. increase her activities that involve weight-bearing.
Correct Answer: D
Rationale: Weight-bearing activities stimulate bone formation, critical for osteoporosis, and improve mobility post-CVA. Options A, B, and C support bone health but are less impactful than exercise for addressing both conditions.
Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
- A. Touring the coronary intensive unit
- B. Mailing a video tape to the home
- C. Assessing the client's learning style
- D. Administering a written pre-test
Correct Answer: C
Rationale: Assessing the client's learning style. Tailoring teaching to the client's learning preferences enhances understanding.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
A client with a gastric ulcer compared to a friend's duodenal ulcer.
The nurse's response should be based on which of the following statements?
- A. Gastric ulcers have an increased association with clients who experience increased psychological pressures.'
- B. The pain of a duodenal ulcer usually occurs two to four hours after meals.'
- C. Clients with gastric ulcers often gain weight, as food alleviates the pain.'
- D. Antacids such as Maalox are seldom prescribed for clients with duodenal ulcers.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) refers to duodenal ulcers (2) correct-clients with duodenal ulcers experience pain after meals, e.g., midmorning and midafternoon (3) gastric ulcer clients may be malnourished because food may cause nausea or vomiting (4) antacids are given to duodenal ulcer clients
The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?
- A. Fat, tendons, and bones
- B. Skin and hair
- C. Nerves, muscle, and blood vessels
- D. Skin, fat, and muscle
Correct Answer: A
Rationale: Fat, tendon, and bone have the most resistance. The higher the resistance, the greater the heat generated by the current, thereby increasing the risk for soft tissue injury. Answer B has intermediate resistance, so it is incorrect. Answer C is incorrect because it has very low resistance. Answer D has low to intermediate resistance, so it is incorrect.