A nurse is speaking with several clients at a health fair. Which of the following statements should the nurse assess further?
"I have to change my hearing aid battery weekly."
"I have to turn my head completely to see things that are beside me."
"I prepare my medications for the week on Sundays."
"I prepare all of my own meals."
The Correct Answer is B
The correct answer is Choice B because, "I have to turn my head completely to see things that are beside me." This statement suggests the possibility of impaired peripheral vision, which could be a safety concern. The nurse should assess further and possibly refer the client for further evaluation.
Choice A is wrong because, "I have to change my hearing aid battery weekly," is not the correct answer as it is a routine self-care task for individuals with hearing aids. Choice C is wrong because, "I prepare my medications for the week on Sundays," is not the correct answer as it is a routine self-care task for individuals who take multiple medications. Choice D is wrong because, "I prepare all of my own meals," is not the correct answer as it is a routine selfcare task for many individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C because, "Clients will schedule bone density screenings." Postmenopausal women are at an increased risk for osteoporosis, and bone density screenings can help identify early signs of the disease, enabling early intervention to prevent complications.
Choice A is wrong because, "Clients will start hormone replacement therapy," is not the correct answer because hormone replacement therapy is not appropriate for all women and can have
negative side effects. It is not an appropriate outcome for an educational program.
Choice B is wrong because, "Clients will significantly decrease caloric intake," is not the correct answer because this outcome is not relevant to postmenopausal women specifically. Additionally, significant caloric restriction can lead to malnutrition and other negative health outcomes.
Choice D is wrong because, "Clients will arrange for mammograms every 3 years," is not the correct answer because while mammograms are an important screening tool for breast cancer, they are not specific to postmenopausal women and should be recommended to all women starting at age 40. Bone density screenings are a more appropriate outcome for a program specifically targeting postmenopausal women.
Correct Answer is A
Explanation
The correct answer is Choice A because, "I am obese because it's in my genes." The client is using rationalization as a coping mechanism by justifying their obesity as being predetermined by their genes, rather than acknowledging their personal responsibility in managing their weight. Rationalization is a defense mechanism in which a person gives a false or socially acceptable explanation for an unacceptable behavior or situation.
Choice B is wrong because, "I have difficulty resisting the items in vending machines," is not the correct answer because it is an excuse rather than a rationalization.
Choice C is wrong because, "I know you don't like me because I am obese," is not the correct answer because it is an example of projection, in which the client attributes their own feelings of dislike to others.
Choice D is wrong because, "I have lots of health problems from being obese," is not the correct answer because it is a justification, not a rationalization
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