A nurse is planning care for a client who wants to lose weight. Which of the following actions should the nurse take first?

Identify the client's motivation.

Refer the client to a dietitian.

Set a weight loss goal.

Discuss behavior modification.

Answer and Explanation

The Correct Answer is A

A) Identify the client's motivation: Understanding the client's motivation for wanting to lose weight is crucial as it helps the nurse tailor interventions and support strategies to align with the client's goals and values. By identifying the client's motivation, the nurse can determine what drives the client's desire to lose weight, whether it's improving health, enhancing self-esteem, or addressing specific concerns. This information forms the foundation for developing an effective and individualized care plan.

B) Refer the client to a dietitian: While a referral to a dietitian is an important step in the weight loss process, it may not be the first action the nurse takes. Before making a referral, it's essential to assess the client's motivation, readiness to change, and current understanding of weight loss strategies. This information helps ensure that the dietitian can provide targeted guidance and support based on the client's specific needs and preferences.

C) Set a weight loss goal: Setting a weight loss goal is an important aspect of the weight loss journey; however, it typically occurs after assessing the client's motivation and readiness to change. Setting realistic and achievable goals collaboratively with the client allows for better engagement and commitment to the weight loss plan. Without understanding the client's motivation and readiness, setting a goal may not be meaningful or sustainable.

D) Discuss behavior modification: Behavior modification strategies play a crucial role in achieving and maintaining weight loss success. However, before discussing specific behavior modification techniques, it's essential to assess the client's motivation, barriers to change, and current behaviors. Understanding these factors helps tailor behavior modification strategies to address the client's unique needs and challenges effectively.

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Correct Answer is D

Explanation

A) 2+ deep tendon reflexes: Deep tendon reflexes are graded on a scale from 0 to 4+, with 2+ indicating normal reflexes. While normal deep tendon reflexes are a positive finding, they do not specifically indicate the effectiveness of treatment for hypernatremia.

B) Urine output 25 mL/hr: Adequate urine output is important for renal function and fluid balance; however, a urine output of 25 mL/hr may be insufficient depending on the client's fluid status and the extent of hypernatremia. This finding alone does not confirm the effectiveness of treatment for hypernatremia.

C) Fatigue: Fatigue is a nonspecific symptom and may not directly reflect the effectiveness of treatment for hypernatremia. While addressing hypernatremia may improve overall well-being and energy levels, fatigue alone is not a definitive indicator of treatment effectiveness.

D) Firm grip bilaterally: This finding indicates normal muscle strength and neuromuscular function, which can be affected by hypernatremia. In hypernatremia, high sodium levels in the blood can lead to neurologic symptoms such as muscle weakness or altered mental status. A firm grip bilaterally suggests that the client's neuromuscular function has returned to baseline, indicating the effectiveness of treatment in correcting the electrolyte imbalance.

A. Client is Rh negative and the newborn is Rh positive. B. Client is Rh positive and the newborn is Rh negative. C. Client is Rh positive and the newborn is Rh positive. D. Client is Rh negative and the newborn is Rh negative.

Correct Answer is A

Explanation

A) Client is Rh negative and the newborn is Rh positive:

This is the correct response. Rho (D) Immunoglobulin, also known as RhoGAM, is administered to Rh-negative mothers who have given birth to Rh-positive infants. This medication helps prevent the mother's immune system from producing antibodies against Rh-positive blood cells, which could lead to hemolytic disease of the newborn in subsequent pregnancies. Administering RhoGAM in this scenario helps prevent sensitization of the mother's immune system to Rh-positive blood cells.

B) Client is Rh positive and the newborn is Rh negative:

Administering RhoGAM to an Rh-positive mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

C) Client is Rh positive and the newborn is Rh positive:

Administering RhoGAM to an Rh-positive mother with an Rh-positive newborn would not be necessary because the mother and newborn share the same Rh factor, so there is no risk of Rh incompatibility.

D) Client is Rh negative and the newborn is Rh negative:

Administering RhoGAM to an Rh-negative mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

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A nurse is planning care for a client who wants to lose weight. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has received treatment for hypernatremia. Which of the following findings indicates the treatment has been effective?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) Immunoglobulin. The nurse should verify which of the following prior to administration?

Correct Answer is A

Explanation

A nurse is teaching a client about protein. Which of the following foods should the nurse include in the teaching as a complete protein? (Select all that apply.)

A nurse is planning eating strategies with a client who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

A nurse is reviewing the laboratory results for a client who started a weight loss program 3 months ago. Which of the following findings is an indication that the program has been effective?

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