The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
The nurse will call the client weekly to monitor the client's blood pressure and symptoms.
The nurse will encourage the client to walk thirty minutes every day.
The client will take up to 4 nitroglycerine tablets sublingually for chest pain.
The client will record episodes of angina and self-management for one week.
The Correct Answer is D
Choice A rationale:
Weekly monitoring of blood pressure and symptoms is important but does not address the specific issue of chest pain on exertion.
Choice B rationale:
Encouraging daily walking is generally a good recommendation for overall health but does not address the immediate concern of chest pain.
Choice C rationale:
Taking up to 4 nitroglycerine tablets for chest pain may provide temporary relief, but this should be done under the guidance of a healthcare provider and is not a long-term outcome.
Choice D rationale:
Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale:
This reflects a potential misunderstanding about the diagnosis and may contribute to stigma. The nurse should provide education and clarify that having acute stress disorder or similar responses to trauma does not mean the client is "crazy."
Choice B rationale:
This statement reflects a positive attitude toward therapy and self-improvement. There is no immediate need for follow-up teaching in this statement, as it aligns with the potential benefits of therapy for coping with trauma.
Choice C rationale:
This indicates the client's interest in holistic approaches, which is positive. However, the nurse should provide information and guidance on the use of such approaches in conjunction with other treatments.
Choice D rationale:
This suggests that the client may believe her response is typical. The nurse should provide education about the variability in individual responses to stress and trauma.
Choice E rationale:
This statement shows an understanding of the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While it's true that having ASD can increase the risk of developing PTSD, this statement does not require immediate follow-up teaching. However, the client should receive ongoing education about managing and preventing PTSD
Choice F rationale:
This raises concerns about the client's expectations regarding the duration of medication. The nurse should provide information about the intended duration of medication and the importance of ongoing assessment and follow-up with healthcare providers.
Correct Answer is D
Explanation
Choice A rationale:
An adult with schizophrenia who often refuses to take prescribed antipsychotic medications may require a different approach, such as medication education or supportive therapy.
Choice B rationale:
A hyperactive 4-year-old who has recently been tested for autism may benefit from play therapy or other age-appropriate interventions rather than role-playing.
Choice C rationale:
An older adult resident of a long-term care facility who sometimes takes other residents' belongings may require interventions focused on behavior management and addressing the underlying causes of this behavior.
Choice D rationale:
Role-playing can be an effective therapeutic intervention for individuals who need to practice social skills, communication, and problem-solving in a safe and controlled environment. In this case, the adolescent who is depressed over not being accepted by peers may benefit from role-playing to develop and practice social skills, assertiveness, and coping strategies for peer interactions.
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