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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

The family member understanding that the nurse can adjust the mother's pain medication as needed indicates an understanding of the nurse's role in managing the patient's symptoms. However, this statement does not demonstrate an understanding of end-of-life care as a holistic process involving various aspects beyond pain management.

Choice B rationale:

This choice reflects a comprehensive understanding of end-of-life care. The family's responsibility to obtain support services shows awareness of the need for a multidisciplinary approach to address physical, emotional, and practical needs during this process. End-of-life care is a collaborative effort, and this choice accurately acknowledges the role of the family in coordinating necessary services.

Choice C rationale:

The statement about prolonging the patient's life through services reflects a misconception about end-of-life care. The focus of end-of-life care is on improving the quality of life and managing symptoms rather than attempting to extend life. This choice suggests a lack of understanding about the terminal nature of the illness.

Choice D rationale:

Believing that the doctor will make all decisions about the patient's care might indicate a lack of involvement or shared decision-making in the care process. End-of-life care often involves discussions among the medical team, patients, and their families to ensure that the patient's wishes and preferences are respected.

A. Encourage fluid intake of 2,500 mL/day. B. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F). C. Immerse the client in cold water. D. Assist the client to ambulate.

Correct Answer is A

Explanation

Choosing the best intervention for a client with fever due to infection:

The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:

a. Encourage fluid intake of 2,500 mL/day.

Rationale:

Pros:Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
Cons:While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.

b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Rationale:

Cons:Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.

c. Immerse the client in cold water.

Rationale:

Cons:Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.

d. Assist the client to ambulate.

Rationale:

Cons:While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.

Therefore, the most appropriate intervention for a client with fever due to infection is:

a. Encourage fluid intake of 2,500 mL/day.

Remember:

Individualize care based on the client's specific needs and preferences.
Monitor the client's response to interventions and adjust as needed.
Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who has a terminal illness about end-of-life care. Which of the following statements by a family member indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

Choosing the best intervention for a client with fever due to infection:

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