The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

Ineffective Sexuality Pattern

Risk for Social Isolation

Activity Intolerance

Imbalanced Nutrition: less than body requirements

Answer and Explanation

The Correct Answer is D

D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.

A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.

C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.

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Correct Answer is D

Explanation

D. Counting the radial pulse for 30 seconds and then multiplying the count by two gives an estimate of the client's heart rate per minute (bpm). This method is efficient and commonly used in clinical practice, especially if the client's pulse is regular.

A. Counting the radial pulse for two minutes is unnecessarily long and not standard practice. Typically, the radial pulse is counted for either 30 seconds or 60 seconds (one minute) to determine the client's heart rate. Multiplying the count by two for a 30-second count or directly using the count for a 60- second count provides the client's beats per minute (bpm).

B. The radial pulse is assessed by palpating the radial artery on the thumb side (or lateral side) of the client's wrist. The nurse places the index and middle fingers gently over the radial artery and applies light pressure to feel the pulse rhythm and rate.

C. Using the thumb to count the pulse is not recommended because the thumb has its own pulse, which could interfere with accurately assessing the client's radial pulse.

A. gender. B. socioeconomic status. C. family's health practices. D. level of education.

Correct Answer is A

Explanation

A. Gender can influence health beliefs and practices due to societal norms, roles, and expectations associated with masculinity and femininity. For example, certain health issues may be more prevalent or

stigmatized based on gender. Understanding a client's gender-related health beliefs can help nurses tailor care that respects and addresses these factors.

B. Socioeconomic status (SES) impacts access to healthcare resources, health literacy, and health behaviors. Clients with higher SES may have greater access to healthcare facilities, medications, and preventive services. However, this is an external variable.

C. Family health practices often shape an individual's beliefs about health and illness. Clients may adopt health behaviors based on familial traditions, cultural practices, or experiences with illness within the family. However, this is an external variable.

D. Education level influences health literacy, understanding of medical information, and decision-making regarding healthcare. Higher education levels are often associated with better health outcomes due to increased knowledge of health-related issues, ability to navigate healthcare systems, and adherence to medical advice. However, this is an external variable.

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The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:

Correct Answer is D

Explanation

The nurse is assessing internal variables that influence a client's health care beliefs and practices. As part of this assessment, the nurse should consider the client's:

Correct Answer is A

Explanation

A nurse is considering ethical principles during rounds. Which nursing statement demonstrates the principle of fidelity?

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