A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make?
“You should try a little harder to stick to your diet.”
“Why do you think you've gained 3 pounds this week?”
“Were there any issues last week that kept you from focusing on your diet?”
“You should put this week behind you and adhere to your diet from this point forward.”
The Correct Answer is C
Choice A reason: This statement is judgmental and discouraging. It implies that the client is not making enough effort and does not acknowledge the possible challenges or barriers that the client may face.
Choice B reason: This statement is accusatory and confrontational. It puts the blame on the client and does not offer any support or guidance.
Choice C reason: This statement is empathetic and supportive. It shows that the nurse is interested in the client's situation and wants to help them identify and overcome any obstacles that may have affected their weight loss.
Choice D reason: This statement is unrealistic and dismissive. It does not address the reasons for the weight gain and does not help the client learn from their experience. It also ignores the emotional impact of the setback.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.
Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.
Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.
Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect action, because covering the insertion site with a hydrocolloid dressing can prevent air from escaping and cause a subcutaneous emphysema, which is a complication of chest tube removal. The insertion site should be covered with a sterile gauze dressing and taped on three sides.
Choice B reason: This is an important action, but not the first one. The nurse should provide pain medication before removal, not immediately after, to reduce the discomfort and anxiety of the client.
Choice C reason: This is the correct action, because auscultating the lungs after removal can help assess the respiratory status and detect any signs of pneumothorax, such as diminished or absent breath sounds.
Choice D reason: This is an incorrect action, because delegating removal of the chest tube to an AP is beyond the scope of practice and can cause harm to the client. The removal of the chest tube should be performed by the nurse or the provider.
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