A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

Anorexia

Emaciation

Cachexia

Nausea

Answer and Explanation

The Correct Answer is A

The nurse should document the client's condition as anorexia. Anorexia refers to the loss of appetite or desire to eat. In this case, the client is reporting a loss of appetite following a prolonged illness, which would be accurately described as anorexia.

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Correct Answer is A

Explanation

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

A. There is one best intervention for each goal/outcome. B. Actions should address the etiology of the nursing diagnosis. C. Interventions should be "doing" not just monitoring. D. Always select independent interventions when possible.

Correct Answer is B

Explanation

When selecting interventions for a care plan, the nurse should consider several principles. One important principle is that actions should address the underlying cause (etiology) of the nursing diagnosis. By addressing the root cause of the problem, interventions can be more eﬀective in achieving the desired outcomes. There is not necessarily one "best" intervention for each goal or outcome, as diﬀerent clients may have diﬀerent needs and respond diﬀerently to interventions. Interventions can include both "doing" actions and monitoring, and both independent and collaborative interventions may be appropriate depending on the situation.

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A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Correct Answer is A

Explanation

Which of the following principles does the nurse use in selecting interventions for the care plan?

Correct Answer is B

Explanation

Which one of the following roles of the home health care nurse illustrates the role of coordinator of services?

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Which of the following statements is true regarding types of health care agencies?

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A nurse is conducting an assessment on a client diagnosed with narcolepsy. The nurse should anticipate which of the following findings? Select all that apply.

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?

During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse hooks the client to the medication infusion. Which role is the nurse performing at this time?

The nurse has performed an assessment of a client scheduled for discharge to be cared for by the family. Which situation would the nurse question regarding discharge of this client to be cared for by the family?