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Questions 157

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Question 1 of 5

The home health-care nurse is visiting an elderly African American female client who is talking loudly. The client weighs 102 kg, is 5'4'' tall, and has a BP of 154/98. The client lives with her daughter, son-in-law, and two grandchildren. Which intervention should the nurse implement?

Correct Answer: D

Rationale: Obesity (BMI ~38) and hypertension (154/98) are health risks; discussing weight loss addresses these priorities. Loud speech may be cultural, not anger; extended eye contact may be disrespectful; and discussing care with family requires consent.

Question 2 of 5

The nurse is preparing to make morning rounds. Which client should the nurse see first?

Correct Answer: C

Rationale: Chest pain, even if possibly dietary, may indicate a cardiac issue, requiring immediate assessment per ABCs. Cultural decision-making, pain refusal, and anger are less urgent.

Question 3 of 5

Which problem is priority for the 24-year-old client diagnosed with endometriosis who is admitted to the gynecological unit?

Correct Answer: B

Rationale: Pain is the priority in endometriosis due to severe dysmenorrhea and pelvic discomfort, per Maslow’s hierarchy, impacting quality of life.

Question 4 of 5

The nurse arranges for a dance movement therapist to lead a group session for clients with osteoarthritis. Which statement best describes the rationale for this intervention?

Correct Answer: D

Rationale: Dance therapy promotes endorphin release, reducing pain perception in osteoarthritis. Bonding is secondary, synovial fluid increase is inaccurate, and pain reduction is less direct.

Question 5 of 5

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy?

Correct Answer: A

Rationale: Cardiomyopathy impairs cardiac output, leading to heart failure, the primary client problem.

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