Nokea
Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?
- A. "I will make sure the menu includes halal options."
- B. "I will ask the client if they want to schedule prayer times during the day."
- C. "I will avoid discussing care when the client's family is around."
- D. "I will make sure daily communion is available for this client."
Correct Answer: B
Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.
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A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
- A. Educating clients about the recommended immunization schedule for adults
- B. Teaching clients how to manage chronic illnesses
- C. Providing counseling for depression
- D. Offering support groups for cancer survivors
Correct Answer: A
Rationale: The correct answer is A: Educating clients about the recommended immunization schedule for adults. This activity falls under primary prevention, which aims to prevent the onset of illness or injury. Immunizations are a proactive measure to protect individuals from developing certain diseases. Choices B, C, and D involve managing chronic illnesses, providing counseling for mental health issues, and offering support for individuals who have already experienced cancer, respectively. These activities are more aligned with secondary or tertiary prevention, focusing on managing existing conditions or preventing complications in those already affected.
A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
- B. I will hold my breath when rising from a sitting position.
- C. I will remove my antiembolic stockings while I am in bed.
- D. I will have my partner help me change positions every 4 hours.
Correct Answer: A
Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.
A healthcare professional is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
- A. Ventrogluteal
- B. Dorsogluteal
- C. Deltoid
- D. Vastus lateralis
Correct Answer: A
Rationale: The ventrogluteal site is considered the safest for intramuscular injections in young adult clients due to its location away from major nerves and blood vessels. The ventrogluteal site is preferred over the dorsogluteal site, as the latter is associated with a higher risk of injury to the sciatic nerve. The deltoid site is commonly used for vaccines but may not be suitable for all intramuscular injections due to smaller muscle mass. The vastus lateralis site is often used in infants and young children, but in young adults, the ventrogluteal site is preferred for safety and efficacy.
A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?
- A. Cough deeply after each use.
- B. Take a deep breath and hold for 10 seconds.
- C. Breathe in slowly and deeply to raise the ball or piston.
- D. Exhale forcefully before using the spirometer.
Correct Answer: C
Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.
A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?
- A. "I am afraid to walk if it hurts too much."
- B. "I don't understand why I need this surgery."
- C. "I don't want my family helping me after the surgery."
- D. "I am afraid the scar will make me look disfigured."
Correct Answer: B
Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.