\What should the nurse teach an older client with TIA?

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Fundamentals of Nursing Nursing Process Questions Questions

Question 1 of 9

\What should the nurse teach an older client with TIA?

Correct Answer: C

Rationale: The correct answer is C: To comply with the medication regimen. Teaching the older client with TIA to comply with medication regimen is crucial in preventing further TIAs or strokes. Medications like antiplatelets or anticoagulants are often prescribed to manage TIA. This education empowers the client to actively participate in their own health management. Incorrect choices: A: Not to worry about the symptoms that are part of the normal aging process - This is incorrect as TIA symptoms are not considered a normal part of aging and should not be ignored. B: To admit oneself to a rehabilitation center or a nursing home for rehabilitation - This is incorrect as it is not the primary intervention for managing TIA. D: To observe any changes in the nails and skin - This is incorrect as it is not directly related to managing TIA.

Question 2 of 9

The nurse is developing a teaching plan for a patient. Which of the following is a modifiable risk factor for the development of hypertension? i.Race iv.Sedentary lifestyle ii.High cholesterol v.Age iii.Cigarette smoking

Correct Answer: C

Rationale: The correct answer is C: 2, 3, and 4. High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for developing hypertension. High cholesterol can lead to atherosclerosis, increasing blood pressure. Smoking can constrict blood vessels, raising blood pressure. Sedentary lifestyle can lead to obesity and overall poor cardiovascular health, contributing to hypertension. Race and age are non-modifiable risk factors. Choice A is incorrect because it includes race, a non-modifiable factor. Choice B is incorrect because it includes age, which is also non-modifiable. Choice D is incorrect because it includes all factors, including non-modifiable ones.

Question 3 of 9

Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:

Correct Answer: A

Rationale: Correct Answer: A: Cover wound with moist sterile dressing Rationale: 1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing. 2. Moist dressing prevents the wound from drying out and minimizes the risk of infection. 3. The moist environment supports healing by promoting cell growth and preventing tissue damage. 4. It protects the exposed bowel from further injury and contamination. Summary: B: Finding out how this happened is important but not an immediate priority for patient care. C: Placing sterile dry gauze can lead to the wound drying out and hinder healing. D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.

Question 4 of 9

Which of the following IV solutions is hypertonic?

Correct Answer: C

Rationale: The correct answer is C: 5% dextrose in 0.9% NaCl. This solution is hypertonic because it has a higher osmolarity compared to the other choices. The presence of dextrose and NaCl in this solution increases its solute concentration, causing water to move out of the cells by osmosis. Normal saline (A) and 0.45% NaCl (B) are isotonic solutions, meaning they have the same osmolarity as body fluids. 0.225% NaCl (D) is a hypotonic solution with lower osmolarity than body fluids.

Question 5 of 9

Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

Question 6 of 9

Which of the following responses indicates sympathetic nervous system function?

Correct Answer: A

Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action. Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.

Question 7 of 9

Which type of neuron transmits impulses from the central nervous system to the muscles and glands?

Correct Answer: B

Rationale: The correct answer is B: Efferent. Efferent neurons transmit signals from the central nervous system to muscles and glands, controlling movement and secretion. Afferent neurons carry signals from sensory receptors to the central nervous system, not towards muscles or glands. "Affective" relates to emotions, not neural function. "Effective" does not describe the direction of signal transmission in the nervous system. Therefore, B is the correct choice.

Question 8 of 9

Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?

Correct Answer: B

Rationale: The correct answer is B. This statement shows an understanding of reducing HIV transmission by promoting harm reduction strategies like needle exchange programs, which help prevent sharing of contaminated needles. This approach is evidence-based and effective in reducing the spread of HIV among injection drug users. Choice A is incorrect because breastfeeding by HIV-positive mothers can transmit the virus to infants. Choice C is incorrect as birth control pills do not protect against HIV, only against pregnancy. Choice D is incorrect as natural skin condoms do not provide the same level of protection against HIV as latex condoms do.

Question 9 of 9

In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

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