A nurse in a community health clinic is caring for a client who expresses plans to quit smoking within the next 2 weeks and requests a prescription for a nicotine patch. Which of the following stages of health behavior change is the client in?

Action

Contemplation

Preparation

Precontemplation

Answer and Explanation

The Correct Answer is C

Rationale:
A. Action: The action stage involves actively implementing strategies to change behavior, such as already using nicotine replacement therapy or abstaining from smoking. Since the client has not yet started quitting but intends to soon, they are not yet in this stage.

B. Contemplation: In this stage, the individual recognizes the need for change but has not yet committed to taking concrete steps. The client requesting a prescription and setting a quit date indicates they have moved beyond contemplation and are preparing for action.

C. Preparation: The preparation stage is characterized by planning to take action within the near future, usually within the next month. The client’s decision to quit within 2 weeks and request a nicotine patch reflects commitment and readiness to initiate behavior change, fitting this stage precisely.

D. Precontemplation: During precontemplation, the individual has no intention of changing behavior and may be unaware of the risks or resistant to advice. This does not apply to the client, who has already expressed motivation and plans to quit smoking soon.

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Correct Answer is C

Explanation

Rationale:
A. Call the pharmacist for clarification of the medication contraindications: While the pharmacist can provide medication information, it is the provider’s responsibility to evaluate the appropriateness of the prescription and modify it if needed.

B. Administer the medication as prescribed: Administering amoxicillin to a client allergic to penicillin places the client at risk for an allergic reaction, including anaphylaxis, since both drugs are in the same class.

C. Discuss the prescription with the health care provider: Amoxicillin is a penicillin derivative and contraindicated for clients with penicillin allergies. The nurse should immediately clarify the prescription with the provider before administration to ensure client safety.

D. Place an incident report in the medical record: Incident reports are used after an error or near-miss has occurred, not before a potential error is prevented. They are also never placed in the client’s medical record.

A. Assess pressure points every 24 hr. B. Turn and reposition the client every 3 hr while in bed. C. Teach the client to shift his weight every 15 min while sitting. D. Place the client upright ona donut-shaped cushion.

Correct Answer is C

Explanation

Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.

B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.

C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.

D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.

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A nurse in a community health clinic is caring for a client who expresses plans to quit smoking within the next 2 weeks and requests a prescription for a nicotine patch. Which of the following stages of health behavior change is the client in?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Correct Answer is C

Explanation

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