A nurse is caring for a client who has coronary artery disease and has a BMI of 30. Which of the following strategies should the nurse implement first to develop teaching that promotes lifestyle changes?
Determine what the client knows about coronary artery disease.
Identify resources that will help support the client's lifestyle changes.
Establish mutual learning goals with the client.
Schedule a teaching session about coronary artery disease in a quiet setting.
The Correct Answer is C
Choice A rationale:
Determining what the client knows about coronary artery disease is an important step in assessing the client's baseline knowledge. However, it's not the first step in developing teaching strategies. First, the nurse should establish a collaborative relationship with the client to set mutual learning goals.
Choice B rationale:
Identifying resources that will help support the client's lifestyle changes is an essential aspect of the teaching process, but it's not the initial step. The nurse needs to work with the client to set goals and develop a plan before seeking external resources.
Choice C rationale:
Establishing mutual learning goals with the client is the most crucial first step. This approach ensures that the teaching plan aligns with the client's needs and preferences, fostering a sense of partnership and increasing the likelihood of successful lifestyle changes.
Choice D rationale:
Scheduling a teaching session about coronary artery disease in a quiet setting is an important consideration for effective teaching, but it comes after the nurse and the client have identified mutual learning goals. The nurse should engage the client in goal-setting before planning specific teaching sessions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The walking gait test is used to assess a client's walking pattern and balance, particularly for identifying abnormalities in gait. However, it doesn't specifically evaluate sensory functions, making it an inappropriate choice for this scenario.
Choice B rationale:
The plantar reflex test, also known as the Babinski reflex test, assesses the neurological integrity of the corticospinal tract. It involves stimulating the sole of the foot to elicit specific reflex movements. While this test is important in assessing neurological function, it doesn't directly evaluate sensory functions as requested in the question.
Choice C rationale:
The finger-to-nose test is a part of the neurological examination used to assess a client's coordination and proprioception. In this test, the client is asked to touch their nose with their index finger while alternating between eyes closed and eyes open. This evaluates their ability to sense the position of their limbs in space (proprioception) and their coordination. It directly addresses the focus of the question, making it the correct choice.
Choice D rationale:
The Romberg test evaluates a client's balance and proprioception. It involves having the client stand with their feet together and their eyes closed to assess their ability to maintain balance without visual input. While this test is relevant to sensory functions, it primarily assesses proprioception and balance rather than coordination, which the question is specifically targeting.
Correct Answer is ["A"]
Explanation
The correct answer is Choice A.
Choice A rationale: Administering enoxaparin 40 mg subcutaneously in the deltoid site is incorrect. Enoxaparin is typically administered in the abdomen or thigh to ensure proper absorption and minimize the risk of injury. Administering it in the deltoid requires an incident report for protocol deviation.
Choice B rationale: Advancing the urinary catheter 18 cm (7 in) is standard practice for male clients to ensure the catheter reaches the bladder. There is no indication of error or the need for an incident report as this action follows proper procedure.
Choice C rationale: Cleansing a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture is standard practice. This action ensures the wound is free from surface contaminants and does not necessitate an incident report.
Choice D rationale: Flushing the tubing of a continuous enteral feeding with 30 mL of water is standard practice to maintain patency and ensure the effectiveness of the feeding. This procedure follows guidelines and does not require an incident report.
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