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Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

Acknowledge feelings of anxiety.

Weigh the client twice weekly.

Encourage exercise.

Provide family education on the condition.

Monitor trips to the restroom.

Allow for menu deviations.

Set precise mealtimes.

Answer and Explanation

Correct Answer : A,B,D,E,G

A. Acknowledge feelings of anxiety: The client's neurological assessment indicates agitation, and acknowledging this can help in addressing any underlying anxiety.
B. Weigh the client twice weekly: Given the client's low BMI and the mother's concern about her weight, regular monitoring is necessary.
C. Encourage exercise: While exercise is generally healthy, the client's current bradycardia and low BMI suggest that immediate physical exertion may not be advisable without medical
supervision.
D. Provide family education on the condition: The client's mother's concern and the client's defensiveness about her weight indicate a need for family education.
E. Monitor trips to the restroom: Monitoring is important to ensure the client is not engaging in behaviors that could further compromise her health, such as purging.
F. Allow for menu deviations is incorrect. Allowing menu deviations can enable the client to avoid certain foods, which reinforces disordered eating behaviors. Structured, balanced meals are essential for recovery.

G. Set precise mealtimes is correct because establishing structured mealtimes promotes consistency and reduces anxiety related to eating. This helps the client develop healthier eating patterns and decreases the urge to binge or purge.

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Correct Answer is D

Explanation

- Choice A Rationale: Assuming care of the client and assigning the PN to another client would disrupt the workflow and could lead to confusion. It is important for continuity of care that the PN who began the procedure with the client carries it through to completion.
- Choice B Rationale: Arranging for unlicensed assistive personnel to assist may not be appropriate as they may not have the training or skills required to assist with a sigmoidoscopy, which could compromise patient safety and the integrity of the procedure.
- Choice C Rationale: Acknowledging that the PN has positioned the client safely and correctly would be incorrect because a flat prone position is not the recommended position for a sigmoidoscopy, which typically requires the client to be in a left lateral or Sims' position.
- Choice D Rationale: Demonstrating to the PN how to position the client more effectively is the correct action because it ensures that the client is in the proper position for a sigmoidoscopy, which can enhance the effectiveness of the procedure and patient comfort.

A. Teach a family member to administer eye drops. B. Encourage deep breathing and coughing exercises. C. Provide an eye shield to be worn while sleeping. D. Obtain vital signs every 2 hours during hospitalization.

Correct Answer is C

Explanation

A. Teaching a family member to administer eye drops may be appropriate for some clients undergoing eye surgery, but it is not specifically indicated for retinal detachment repair.
B. Encouraging deep breathing and coughing exercises is important for preventing respiratory complications but is not directly related to postoperative care for retinal detachment repair.
C. Providing an eye shield to be worn while sleeping is important to protect the eye and prevent inadvertent trauma during the vulnerable postoperative period. It helps promote healing and
prevents further injury to the eye.
D. Obtaining vital signs every 2 hours during hospitalization is a general nursing intervention but is not specific to the postoperative care of a client undergoing retinal detachment repair.

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Exhibits Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

A client is scheduled for an IV pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.