A client has hypertension and high risk factors for cardiovascular disease.
The client is overwhelmed with the recommended lifestyle changes.
What action by the nurse is best?
Assess the client's support system.
Assist in finding one change the client can control.
Determine what stressors the client faces in daily life.
Inquire about delegating some of the client's obligations.
The Correct Answer is B
Choice A rationale
Assessing the client's support system is a valuable step, but it is not the best initial action. Overwhelmed clients need to feel a sense of control over their situation before they can effectively utilize external support. Focusing on one manageable change empowers the client, which is a more immediate and effective intervention for dealing with feelings of being overwhelmed.
Choice B rationale
Overwhelmed clients often feel a lack of control and competence. By assisting the client to identify and focus on a single, achievable lifestyle change, the nurse can help the client experience a sense of mastery and success. This positive experience can build confidence and motivation, making it more likely for the client to attempt and sustain further lifestyle changes.
Choice C rationale
While understanding a client's stressors is important for holistic care, this information may further overwhelm a client who is already feeling burdened. The immediate priority is to help the client feel capable of making a change. By first focusing on one small, manageable step, the nurse can begin to empower the client and then address broader stressors later.
Choice D rationale
Inquiring about delegating obligations may not be practical or appropriate for many clients and does not directly address the core issue of feeling overwhelmed by lifestyle changes. This suggestion externalizes the problem and does not empower the client to take control of their health. The focus should be on internal motivation and self-efficacy, not simply shifting responsibilities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.
Choice B rationale
Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.
Choice C rationale
Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.
Choice D rationale
Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.
Correct Answer is D
Explanation
Choice A rationale
There is no conclusive scientific evidence to support the claim that specific foods like chocolate, peanuts, and cola directly cause or worsen acne. Acne is a multifactorial condition primarily driven by hormonal changes, sebum production, follicular hyperkeratinization, and the bacteria Propionibacterium acnes. While a high glycemic diet may be linked to acne, there is no direct causal link with these specific foods.
Choice B rationale
Over-washing the face with harsh cleansing products can strip the skin of its natural oils (sebum), leading to a rebound effect where the sebaceous glands produce even more oil. This can exacerbate acne by creating a more favorable environment for bacterial proliferation and follicular clogging. Gentle cleansing twice a day is recommended, not frequent washing, to maintain skin barrier integrity.
Choice C rationale
Moderate sun exposure can be beneficial for some individuals with acne. Ultraviolet (UV) light has anti-inflammatory and antibacterial properties that can reduce the population of Propionibacterium acnes. Avoiding sun exposure completely is not a standard recommendation for acne prevention, although excessive sun exposure can lead to other skin problems and should be avoided.
Choice D rationale
Stress and lack of rest can increase cortisol levels, which can stimulate sebum production and inflammation, contributing to acne formation. A balanced diet provides essential vitamins and minerals for skin health, and sufficient rest helps regulate hormonal balance. Promoting overall well-being through diet and rest indirectly supports skin health and can help in the prevention of acne.
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