The nurse is identifying goals of care for a patient with stress incontinence. Which goal would be a priority for this patient?

Correct Answer: D

Rationale: Stress incontinence is commonly caused by the weakening of the pelvic floor muscles that support the bladder and urethra. Thus, a priority goal for a patient with stress incontinence would be to strengthen these muscles through pelvic floor muscle exercises. By performing these exercises as taught by the nurse at least twice a day, the patient can improve the support to the bladder and reduce or manage the symptoms of stress incontinence. This proactive approach addresses the root cause of the issue and can lead to significant improvement in the patient's condition over time. Understanding the chronic and benign nature of the disorder (Option A), identifying protective products (Option B), and limiting intake of certain beverages (Option C) can also be important aspects of care but may not directly address the underlying cause as effectively as pelvic floor muscle exercises.

Correct Answer: D

Rationale: An Unna boot is a type of compression bandage that is impregnated with zinc oxide paste. This paste helps to provide a moist environment for the wound, which can promote healing and also has antimicrobial properties. The compression from the Unna boot helps to reduce swelling and improve circulation in the affected area, which is beneficial for treating stasis ulcers. By understanding that an Unna boot contains zinc oxide paste, the home care nurse can ensure proper application and effectiveness in promoting wound healing.

Correct Answer: D

Rationale: Tobacco use is a modifiable risk factor for hypertension. Smoking cigarettes can lead to an increase in blood pressure and heart rate, as well as damage to blood vessels, which can contribute to the development of hypertension. By quitting smoking or avoiding tobacco use, individuals can reduce their risk of developing hypertension and improve their overall cardiovascular health. On the other hand, factors such as age, ethnicity, and family history are non-modifiable risk factors for hypertension, meaning individuals cannot change them through lifestyle modifications.

Correct Answer: D

Rationale: Asking the client about their preferred learning strategies is the appropriate action at this time. Everyone learns in different ways, and by identifying the client's preferred learning style, the nurse can tailor the teaching session to be more effective and memorable for the client. Understanding how the client learns best can help in providing information in a way that is easier for them to retain and recall later. It also demonstrates a client-centered approach to teaching, which can improve communication and understanding between the client and the healthcare provider.

Correct Answer: B

Rationale: Ineffective Protection is a nursing diagnosis that involves a compromised ability to guard against health threats. Patients with systemic lupus erythematosus are prone to skin rashes, lesions, and photosensitivity due to the autoimmune nature of the disease. Providing appropriate skincare is essential in managing the skin manifestations of lupus, such as using gentle cleansers, moisturizers, and sunscreen to protect the skin from further damage. Proper skincare can help maintain skin integrity and prevent infections, which are crucial aspects of protecting patients with systemic lupus erythematosus. While monitoring laboratory findings, practicing careful hand hygiene, and administering prescribed medications are all important aspects of care for lupus patients, providing appropriate skincare directly addresses the Ineffective Protection diagnosis by focusing on protecting the patient's skin health.

Correct Answer: A

Rationale: The priority action by the nurse when a client receiving heparin therapy for deep venous thrombosis (DVT) presents with symptoms suggestive of a pulmonary embolism, such as severe chest pain and shortness of breath, is to assess the client's pulse, respirations, and blood pressure. These vital signs will provide crucial information about the client's current cardiovascular and respiratory status, which is essential for determining the severity of the condition and guiding immediate interventions. Assessing these vital signs will help the nurse quickly identify any signs of hemodynamic instability or respiratory distress, enabling prompt and appropriate treatment to be initiated. Once the assessment is done, further interventions such as oxygen therapy and notifying the healthcare provider can be implemented as needed.

Correct Answer: B

Rationale: Clopidogrel (Plavix) is an antiplatelet medication commonly prescribed during the acute care phase immediately after a stroke. This medication helps prevent blood clots from forming by inhibiting platelets in the blood. It is essential during the acute phase to prevent further blockages in the blood vessels that could lead to more strokes or complications. Once the acute phase is managed, other medications may be incorporated during the recovery, stroke prevention, and rehabilitation stages depending on the individual's condition and risk factors.

Correct Answer: C

Rationale: - Activity C, where class members demonstrate a favorite nursing skill for the class, falls within the affective domain of Bloom's taxonomy. This activity involves showcasing a personal preference and emotional connection to a particular skill, demonstrating feelings and attitudes towards it.

Correct Answer: B

Rationale: Smoking is a major risk factor for developing heart failure. African Americans are at a higher risk of heart failure compared to Caucasians. Additionally, being female and smoking further increase the risk. Smoking damages the blood vessels and heart, leading to various cardiovascular problems including heart failure. Therefore, the 50-year-old African American female who smokes is at the greatest risk of developing heart failure among the given options.