The RN has completed an assessment on a client. What should the nurse do next?
Reassess the patient
Write nursing interventions
Analyze cues
Create SMART goals
The Correct Answer is C
Choice A reason: This is not the correct answer because reassessing the patient is not the next step after completing an assessment. Reassessment is done periodically or when there is a change in the patient's condition, but not immediately after the initial assessment.
Choice B reason: This is not the correct answer because writing nursing interventions is not the next step after completing an assessment. Nursing interventions are the actions that the nurse plans and implements to achieve the desired outcomes for the patient. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Choice C reason: This is the correct answer because analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns, relationships, and trends in the assessment data, and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient's problems, needs, strengths, and risks.
Choice D reason: This is not the correct answer because creating SMART goals is not the next step after completing an assessment. SMART goals are the specific, measurable, achievable, realistic, and time-bound outcomes that the nurse and the patient agree on. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Vitamin D is a fat-soluble vitamin that helps the body absorb calcium and phosphorus, which are essential for bone health. The main source of vitamin D is exposure to sunlight, which triggers the skin to produce it. The nurse should advise the client to spend at least 15 minutes outdoors every day, preferably in the morning or evening, when the sun is not too strong. The client should also wear sunscreen and protective clothing to prevent sunburn and skin damage.
Choice B reason: Reducing the amount of cereal in the diet is not a good recommendation for increasing vitamin D intake. Cereal is often fortified with vitamin D and other nutrients, such as iron and folic acid. The nurse should encourage the client to choose cereals that are high in vitamin D and low in sugar and fat. The client should also consume other foods that are rich in vitamin D, such as fatty fish, egg yolks, cheese, and mushrooms.
Choice C reason: Increasing intake of dietary calcium is important for preventing and treating osteoporosis, but it does not directly affect vitamin D intake. Calcium is a mineral that helps build and maintain strong bones and teeth. The nurse should recommend the client to consume foods that are high in calcium, such as dairy products, leafy greens, nuts, and tofu. The client should also take a calcium supplement if needed, as prescribed by the provider.
Choice D reason: Adding a regular exercise routine is beneficial for improving overall health and well-being, but it does not directly influence vitamin D intake. Exercise helps strengthen the muscles and bones, prevent falls and fractures, and reduce the risk of chronic diseases. The nurse should suggest the client to engage in moderate physical activity for at least 30 minutes a day, three times a week. The client should choose exercises that are appropriate for their age and fitness level, such as walking, swimming, or yoga.
Correct Answer is A
Explanation
Choice A reason: Tachycardia is a physiological response to fear and anxiety. Tachycardia is a condition where the heart rate is faster than normal, usually above 100 beats per minute. Fear and anxiety can trigger the release of stress hormones, such as adrenaline and cortisol, that stimulate the sympathetic nervous system. This causes the heart to beat faster and stronger, increasing the blood flow and oxygen delivery to the muscles and organs. This prepares the body for the fight-or-flight response, which is a survival mechanism that helps the person to cope with a perceived threat or danger.
Choice B reason: Bronchial constriction is not a physiological response to fear and anxiety. Bronchial constriction is a condition where the airways in the lungs become narrow and inflamed, reducing the airflow and causing difficulty breathing. Bronchial constriction can be caused by various factors, such as asthma, allergies, infections, or irritants. Fear and anxiety can worsen the symptoms of bronchial constriction, but they are not the primary cause of it.
Choice C reason: Bradypnea is not a physiological response to fear and anxiety. Bradypnea is a condition where the breathing rate is slower than normal, usually below 12 breaths per minute. Bradypnea can be caused by various factors, such as brain injury, drug overdose, sleep apnea, or metabolic disorders. Fear and anxiety can increase the breathing rate, not decrease it, as the body needs more oxygen to cope with the stress.
Choice D reason: Pupillary constriction is not a physiological response to fear and anxiety. Pupillary constriction is a condition where the pupils in the eyes become smaller and less responsive to light. Pupillary constriction can be caused by various factors, such as eye injury, medication, aging, or neurological disorders. Fear and anxiety can cause pupillary dilation, not constriction, as the pupils widen to allow more light and improve the vision. This helps the person to see better and react faster to the situation.
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