the nurse is obtaining a health history from a new patient which data will be the focus of patient teaching
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. During a health history assessment of a new patient, which data should be the focus for patient teaching?

Correct answer: B

Rationale: The correct answer is saturated fat intake. Behaviors play a crucial role in health outcomes, and saturated fat intake is a modifiable behavior that can significantly impact a patient's health. By focusing on educating the patient about reducing saturated fat intake, the healthcare provider can empower the patient to make positive changes. While age, gender, ethnicity, and family history are important factors in understanding a patient's health status, they are not behaviors that can be directly modified through patient teaching. Therefore, these factors are essential for developing an individualized care plan but are not the primary focus of patient teaching. Saturated fat intake directly relates to dietary habits, which can be altered through education and support to promote better health outcomes.

2. A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:

Correct answer: A

Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.

3. A writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially, the nurse should plan this for a manic client:

Correct answer: A

Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.

4. A client with asthma is being admitted for breathing difficulties. His arterial blood gas results are pH 7.26, PCO2 49, PaO2 90, and HCO3- 21. Which of the following best describes this condition?

Correct answer: A

Rationale: In this case, the client's arterial blood gas results show a pH of 7.26 and a PCO2 of 49, both of which are abnormal. A pH below the normal range of 7.35-7.45 indicates acidosis. The elevated PCO2 of 49 mmHg suggests respiratory acidosis as the primary issue. The normal range for PCO2 is 35-45 mmHg, so a value of 49 indicates the retention of excess CO2, leading to acidosis. The low HCO3- level of 21 also supports the presence of metabolic acidosis; however, the primary abnormality is respiratory, making this an uncompensated respiratory acidosis. Therefore, the correct answer is 'Uncompensated respiratory acidosis.' Choice B, 'Compensated respiratory alkalosis,' is incorrect because the client's pH is acidic, not alkalotic. Additionally, there is no compensation occurring for the primary respiratory acidosis indicated by the elevated PCO2. Choice C, 'Uncompensated metabolic acidosis,' is incorrect because while the HCO3- level is low, the primary issue indicated by the elevated PCO2 is respiratory acidosis. Choice D, 'Compensated metabolic alkalosis,' is incorrect since the arterial blood gas results do not support a metabolic alkalosis. The low HCO3- level would typically be seen in metabolic acidosis, but in this case, the primary issue is respiratory acidosis.

5. The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

Correct answer: B

Rationale: To prevent the transmission of pulmonary tuberculosis, it is important for the infected individual to minimize exposure to close contacts and household members. Sleeping alone in a separate room, like the guest bedroom, is an effective measure. The other choices are not ideal: Choice A is incorrect because spending time outdoors is encouraged for ventilation; Choice C is incorrect as using public transportation increases the risk of transmission; Choice D is incorrect because keeping windows closed limits ventilation, which is necessary to reduce the concentration of infectious particles in the air.

Similar Questions

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Which of the following is an example of intragroup conflict?
An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?
A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?

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