A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect? (Select all that apply.)

Ability to dress himself

Ability to identify how often he should schedule his car for an oil change

Ability to bathe himself

Ability to perform oral hygiene

Ability to balance his bank account

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: The ability to dress oneself is a basic ADL and is important for independence after discharge.

Choice B reason: Scheduling car maintenance is not considered a basic ADL; it is an instrumental activity of daily living (IADL), which is not typically assessed for depression-related ADLs.

Choice C reason: The ability to bathe oneself is another basic ADL that is crucial for self-care and should be assessed before discharge.

Choice D reason: Performing oral hygiene is a fundamental ADL and should be included in the assessment.

Choice E reason: Balancing a bank account is an IADL and, similar to choice B, is not typically part of the basic ADL assessment for a client with depression.

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Correct Answer is D

Explanation

Choice A reason: Encouraging the client to sleep during the day can disrupt the normal sleep-wake cycle and is not recommended for managing insomnia associated with depression.

Choice B reason: Scheduling a brisk physical activity before bedtime can be stimulating and may actually make it more difficult for the client to fall asleep.

Choice C reason: Monitoring for bouts of diarrhea is not directly related to the care of a client with severe depression unless the client is on specific medications that may cause gastrointestinal upset as a side effect.

Choice D reason: Offering frequent small snacks can help manage the weight loss and decreased appetite often seen in clients with severe depression, ensuring they receive adequate nutrition.

A. Lack of sufficient oxygen to the myocardium. B. Increased cardiac workload. C. Interrupted electrical activity to areas of the heart. D. Lack of nutrients to the heart.

Correct Answer is A

Explanation

Choice A reason: The myocardium requires a constant supply of oxygen to function properly. Coronary artery disease (CAD) causes a reduction in blood flow due to narrowed or blocked coronary arteries, leading to a lack of oxygen in the heart muscle, which can result in angina or chest pain.

Choice B reason: While increased cardiac workload can exacerbate chest pain, it is not the primary cause of pain in CAD. The pain is primarily due to ischemia, which is the lack of oxygen and nutrients to the heart tissue due to reduced blood flow.

Choice C reason: Interrupted electrical activity can lead to arrhythmias or heart attack, but it is not the direct cause of pain in CAD. The pain is related to ischemia, not electrical disturbances.

Choice D reason: A lack of nutrients, including oxygen, to the heart does contribute to the pain experienced in CAD; however, the primary factor is the insufficient oxygen supply, which is explicitly stated in choice A.

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A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is newly admitted with severe depression. Which of the following actions should be added to the plan of care?

Correct Answer is D

Explanation

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

Correct Answer is A

Explanation

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