Nokea
While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.
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The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
- A. The termination stage begins with the initial group meeting.
- B. Members' feelings about their accomplishments are explored in the working stage.
- C. During the working stage, members may be unclear about the purpose of the group.
- D. Group roles and responsibilities are established in the working stage of group therapy.
Correct Answer: D
Rationale: In group therapy, roles and responsibilities are established during the working stage, as members actively engage. Termination (A) occurs at the end, feelings about accomplishments (B) are explored in termination, and unclarity about purpose (C) occurs in the forming stage.
The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
- A. Low serum albumin level
- B. Low serum transferrin level
- C. High hemoglobin level
- D. High cholesterol level
Correct Answer: A
Rationale: Long-term protein deficiency significantly lowers serum albumin levels. Albumin, derived from protein breakdown, is produced by the liver when adequate amino acids are available. Due to its long half-life, acute protein loss minimally affects serum albumin levels. In contrast, serum transferrin, with a shorter half-life of 8 to 10 days, decreases with acute protein deficiency and is not a reliable indicator of chronic protein malnutrition. Elevated hemoglobin levels may occur in conditions like dehydration or chronic obstructive pulmonary disease, making it an unreliable indicator of chronic protein malnutrition. High cholesterol levels are not directly linked to protein malnutrition and do not serve as a reliable indicator. Therefore, the most reliable indicator of chronic protein malnutrition among the options provided is a low serum albumin level.
The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a 'tearing' sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the nurse make?
- A. Try not to worry, you and your baby are in good hands.'
- B. I understand your concerns. I'll let your health care provider know you need to talk.'
- C. I don't have time to answer questions now but I'll plan for us to have time to talk later.'
- D. I can understand that you are fearful. We are doing everything possible for your baby.'
Correct Answer: D
Rationale: Clients have a concern for the safety of their baby during labor and delivery, especially when a problem arises. Empathy and a calm attitude with realistic reassurances are important aspects of client care. Dismissing or ignoring the client's concerns can lead to increased fear and a lack of cooperation. Option 1 uses a cliché and provides false reassurance. Options 2 and 3 place the client's feelings on hold.
An adolescent is preparing to return home after psychiatric hospitalization for a suicide attempt. Which actions would be most effective to support family processes when the client returns home?
- A. Make a video of the ride home in the car.
- B. Identify the family's strengths and weaknesses.
- C. Ask that the mother's boyfriend move out of the home.
- D. Provide and offer the family appropriate options and resources.
- E. Encourage communication and the sharing of feelings among the family members.
Correct Answer: B,D,E
Rationale: After the crisis time of a family member's suicide attempt, safety for the recovering individual is a priority. Families can provide support and encouragement in a caring home environment. Options 2, 4, and 5 offer helpful ways to enhance the family processes. Options 1 and 3 are clearly the least effective options because there is no information in the question that indicates that these actions are relative to the suicide attempt.
The nurse prepares a client for a left total hip replacement. Which statement by the client indicates to the nurse that the client exhibits an emotional readiness for surgery?
- A. I know the health care provider isn't telling me everything, but there is nothing I can do about it.
- B. I've never heard of this specialist before. Does this health care provider do much work here?
- C. I'm glad the trapeze is here so I can start working on my exercises as soon as I wake up.
- D. Can you please check my chart? I'm not sure that other nurse recorded that I am a diabetic.
Correct Answer: C
Rationale: Expressing enthusiasm for post-surgical exercises indicates optimism and readiness to engage in recovery, reflecting emotional preparedness. Other statements suggest distrust, uncertainty, or anxiety, which do not indicate readiness.