Nokea
A man is seen in the outpatient clinic for treatment of hypertension. The client expresses concern to the nurse that his wife has been unemployed for more than six months. He is afraid that soon they will be unable to pay their rent.
Which of these responses by the nurse would be BEST?
- A. These things always have a way of working themselves out.'
- B. It's important for your health that you not worry too much.'
- C. You're worried that you won't be able to pay the rent?'
- D. A social worker might be able to help you with this problem.'
Correct Answer: C
Rationale: Strategy: 'BEST' indicates there may be more than one response you will like. Remember therapeutic communication. (1) minimizes client's concerns (2) minimizes client's concerns and places pressure on client to avoid feelings (3) correct-reflective response, would encourage discussion of feelings and concerns (4) passing the buck, nontherapeutic
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The primary purpose for using a CPM machine for the client with a total knee repair is to help:
- A. Prevent contractures.
- B. Promote flexion of the artificial joint.
- C. Decrease the pain associated with early ambulation.
- D. Alleviate lactic acid production in the leg muscles.
Correct Answer: A
Rationale: A CPM machine prevents contractures by maintaining joint mobility post-knee repair. It aids flexion but primarily prevents stiffness. Pain and lactic acid are secondary concerns.
A client is admitted with rheumatoid arthritis. Which symptoms, if exhibited by the client, are most consistent with the admitting diagnosis?
- A. A 72-year-old with pain, redness, and swelling in the big toes
- B. A 68-year-old with enlarged finger joints and pain in the knees
- C. A 34-year-old with joint pains and a red rash on the cheeks
- D. A 28-year-old with enlarged joints and painful muscles
Correct Answer: B
Rationale: Rheumatoid arthritis causes symmetrical joint inflammation, leading to enlarged, painful joints like fingers and knees. Toe pain suggests gout, rash suggests lupus, and muscle pain is less specific.
A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and requests to be suctioned.
The nurse understands that the client's attention-seeking behaviors may be due to
- A. anger and frustration.
- B. awareness of vulnerability.
- C. increased social isolation.
- D. increased sensory stimulation.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not accurate for situation (2) correct-is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation
The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?
- A. A 56-year-old who was admitted last evening vomiting blood; the night nurse says he has had no emesis for the last four hours
- B. A 65-year-old who had hip replacement surgery two days ago
- C. A 68-year-old who fell yesterday and is scheduled for hip surgery later this morning
- D. A 69-year-old who was admitted last evening with severe right upper quadrant and right scapular pain
Correct Answer: A
Rationale: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is MOST appropriate?
- A. Limit exercise to once a week.
- B. Consume a high-sodium diet.
- C. Lose weight if overweight.
- D. Increase alcohol intake.
Correct Answer: C
Rationale: Weight loss reduces blood pressure in hypertensive clients. Options A, B, and D worsen hypertension.