A nurse is assisting with the care of a client who is experiencing stress. Which of the following actions should the nurse take first?
Establish short- and long-term goals for the client.
Review the client's condition to determine if the plan was effective.
Develop a statement about the client's health alteration.
Conduct a mental status exam for the client.
The Correct Answer is D
A. Establish short- and long-term goals for the client:
Goal-setting is part of planning care and is important, but it requires baseline data from an assessment first. You shouldn’t set goals until you know the client’s current mental and physical status.
B. Review the client's condition to determine if the plan was effective:
Evaluating effectiveness comes after interventions have been implemented. It is not the first action when a client presents with stress.
C. Develop a statement about the client's health alteration:
Writing a nursing diagnosis or problem statement is part of planning and requires initial assessment data; it is not the immediate first action.
D. Conduct a mental status exam for the client:
The first action is to assess - a mental status exam provides objective baseline data (orientation, affect, cognition, thought processes) needed to prioritize problems, detect safety risks (e.g., suicidality), and guide immediate interventions. Assessment precedes planning and evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Leakage of urine:
Urinary retention can cause overflow incontinence or dribbling when the bladder becomes overdistended and small amounts of urine leak past the sphincter; paradoxical leakage is a classic sign of retention.
B. Cloudy urine:
Cloudy urine may indicate infection, crystalluria, or concentrated urine, but it is not a defining sign of urinary retention. Retention predisposes to infection over time, but cloudiness is not expected in every case.
C. Blood in urine:
Hematuria is not a typical direct manifestation of uncomplicated urinary retention; it suggests trauma, infection, stone disease, or other pathology and would prompt further investigation.
D. Dark-colored urine:
Dark urine may reflect dehydration, concentrated urine, or pigments/medications; while retention can alter urine appearance indirectly, dark urine is not a characteristic finding used to diagnose urinary retention.
Correct Answer is C
Explanation
A. "Try to defecate at different times of the day.":
Establishing a regulartoileting schedule (usually after meals when gastrocolic reflex is strongest, e.g., morning or after breakfast) is recommended to promote regular bowel habits. Varying times undermines routine and makes it harder to train the bowel.
B. "Reduce your daily activity.":
Physical activity stimulates intestinal motility and helps prevent constipation. Patients should be encouraged to increase activity (as tolerated) rather than reduce it.
C. "Increase your daily fluid intake.":
Adequate hydration softens stool and facilitates bowel movements; increasing daily fluid intake (commonly aiming for about 2 liters unless contraindicated) is a key nonpharmacologic measure to relieve and prevent constipation.
D. "Consume a low-fiber diet.":
A high-fiber diet (fruits, vegetables, whole grains) increases stool bulk and promotes motility, helping prevent constipation. Low-fiber diets are more likely to contribute to constipation.
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