A nurse on a medical-surgical unit knows that for clients with a BMI greater than or equal to 30, it is important to:

Utilize supine positioning to maximize chest expansion.

Use an appropriately sized blood pressure cuff.

Consult a nutritionist because the client is malnourished/underweight.

Place the client on fall precautions because of increased risk for falls due to frail bones.

Answer and Explanation

The Correct Answer is B

Choice A reason: Utilize supine positioning to maximize chest expansion is not an important intervention for clients with a BMI greater than or equal to 30. Supine positioning is when the client lies flat on their back. This position can actually impair chest expansion and breathing for clients with a high BMI, as the weight of the abdomen and chest can compress the lungs and diaphragm. A semi-Fowler's position, where the head of the bed is elevated at 30 to 45 degrees, is preferred for these clients, as it reduces the pressure on the chest and improves ventilation.

Choice B reason: Use an appropriately sized blood pressure cuff is an important intervention for clients with a BMI greater than or equal to 30. A blood pressure cuff that is too small or too tight can cause inaccurate readings and increase the risk of injury to the client. A blood pressure cuff that is too large or too loose can also cause inaccurate readings and compromise the quality of care. A blood pressure cuff that fits the client's arm circumference and width is essential for obtaining accurate and reliable measurements and preventing complications.

Choice C reason: Consult a nutritionist because the client is malnourished/underweight is not an important intervention for clients with a BMI greater than or equal to 30. A BMI greater than or equal to 30 indicates that the client is obese, not malnourished or underweight. Obesity is a condition where the client has excess body fat that can affect their health and well-being. Malnutrition is a condition where the client has inadequate or imbalanced intake of nutrients that can affect their growth and development. Underweight is a condition where the client has a low body weight that can affect their immunity and energy. A nutritionist can help clients with any of these conditions, but the statement is incorrect for clients with a high BMI.

Choice D reason: Place the client on fall precautions because of increased risk for falls due to frail bones is not an important intervention for clients with a BMI greater than or equal to 30. Frail bones are not a common consequence of obesity, but rather of osteoporosis, a condition where the bones become weak and brittle. Obesity can actually increase the bone density and strength, as the bones have to support more weight. However, obesity can increase the risk for falls due to other factors, such as impaired mobility, balance, or coordination. Fall precautions are important for any client who is at risk for falls, but the statement is inaccurate for clients with a high BMI.

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Correct Answer is A

Explanation

Choice A reason: Administering a vaccine to a well child is an example of the RN working in a health promotion role through primary prevention. Primary prevention is the level of prevention that aims to prevent disease or injury before it occurs. It involves reducing exposure to risk factors and enhancing protective factors. Vaccination is a primary prevention strategy that protects the child from contracting or spreading infectious diseases, such as measles, polio, or tetanus.

Choice B reason: Obtaining a blood glucose level on a client with hypoglycemia (low blood sugar) is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through tertiary prevention. Tertiary prevention is the level of prevention that aims to reduce the complications and disability associated with chronic or irreversible diseases or injuries. It involves providing treatment, rehabilitation, and support services. Obtaining a blood glucose level on a client with hypoglycemia is a tertiary prevention strategy that monitors the client's condition and prevents further deterioration or complications, such as coma or seizures.

Choice C reason: Educating a patient on wound care is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through secondary prevention. Secondary prevention is the level of prevention that aims to detect and treat diseases or injuries early, before they become more serious or chronic. It involves screening, diagnosis, and intervention. Educating a patient on wound care is a secondary prevention strategy that helps the patient to prevent infection, promote healing, and avoid complications, such as scarring or gangrene.

Choice D reason: Administering a nebulizer treatment to a client with asthma is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through tertiary prevention. Tertiary prevention is the level of prevention that aims to reduce the complications and disability associated with chronic or irreversible diseases or injuries. It involves providing treatment, rehabilitation, and support services. Administering a nebulizer treatment to a client with asthma is a tertiary prevention strategy that helps the client to relieve symptoms, improve lung function, and prevent exacerbations, such as asthma attacks.

A. Gradual loss of peripheral vision B. Gradual loss of central vision C. Sudden headache and nausea D. Cloudy blurred vision

Correct Answer is A

Explanation

Choice A reason: Gradual loss of peripheral vision is a characteristic symptom of open-angle glaucoma, which is the most common type of glaucoma. It occurs when the drainage angle of the eye becomes blocked, causing increased intraocular pressure and damage to the optic nerve.

Choice B reason: Gradual loss of central vision is more typical of age-related macular degeneration, which is a condition that affects the macula, the central part of the retina. It is not a symptom of open-angle glaucoma.

Choice C reason: Sudden headache and nausea are signs of acute angle-closure glaucoma, which is a medical emergency that requires immediate treatment. It occurs when the drainage angle of the eye suddenly closes, causing a rapid rise in intraocular pressure and severe pain.

Choice D reason: Cloudy blurred vision is a symptom of cataract, which is a condition that causes the lens of the eye to become cloudy and opaque. It is not a symptom of open-angle glaucoma.

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A nurse on a medical-surgical unit knows that for clients with a BMI greater than or equal to 30, it is important to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is an example of the RN working in a health promotion role through primary prevention?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following symptoms should the nurse expect the patient to report?

Correct Answer is A

Explanation

Physiological response to fear and anxiety includes which of the following?

The RN has completed an assessment on a client. What should the nurse do next?

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Identify which client could be considered to be in a state of wellness?

A nurse is caring for a client who states, "I did not take my medication because my partner forgot to remind me." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

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