An older adult client is preparing for discharge following a myocardial infarction (MI). The nurse is reviewing the prescribed cardiac diet and exercise instructions with the client. Which action should the nurse implement while teaching?

Provide handouts written at a 12th grade reading level.

Use background music to promote relaxation.

Turn on overhead lights while giving instructions.

Stand behind the client to avoid intimidation.

Answer and Explanation

The Correct Answer is C

A. Provide handouts written at a 12th grade reading level: Educational materials should be written at an appropriate reading level for the client, typically 6th to 8th grade for older adults, to promote understanding. Handouts at a 12th-grade level might be too complex.

B. Use background music to promote relaxation: While this could potentially help reduce anxiety for some people, it may also be distracting for others during important health teaching. The priority is clear and focused communication.

C. Turn on overhead lights while giving instructions: Proper lighting is essential, especially for older adults who may have visual impairments. Bright, direct lighting can help ensure the client clearly sees instructional materials and feels more comfortable during teaching.

D. Stand behind the client to avoid intimidation: Standing behind the client can be intimidating and might make the interaction feel less personal. It's important to engage the client in a way that encourages open communication, typically by sitting or standing at eye level.

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Correct Answer is {"dropdown-group-1":"A"}

Explanation

Rationale for Correct Choice:

Depression: The client has symptoms of depression, such as general malaise, fatigue, decreased appetite, withdrawal, flat affect, and poor hygiene. Additionally, the client reports a significant change in sleep patterns, with an inability to sleep at night. His alcohol consumption could also contribute to depressive symptoms.

Rationale for Incorrect Choices:

Anxiety disorder: While anxiety can cause fatigue, disrupted sleep, and lack of energy, it typically also presents with heightened nervousness, restlessness, excessive worry, or physical symptoms like rapid heart rate, which are not reported here. The client's withdrawal and lack of energy are more consistent with depression.
Hypothyroidism: Hypothyroidism can cause fatigue, weight gain, and poor appetite, but the client's low BMI (17.7 kg/m²) suggests that weight loss, rather than gain, is occurring. Additionally, the lack of other hypothyroid symptoms, like constipation or cold intolerance, makes hypothyroidism less likely than depression in this scenario.

A. Perform active range of motion exercises. B. Apply compression stockings. C. Give antispasmodic medications. D. Massage the extremities twice a week.

Correct Answer is C

Explanation

A. Perform active range of motion exercises: Active ROM exercises are beneficial for maintaining joint mobility and circulation, but they may not sufficiently reduce spasticity in clients with upper motor neuron lesions.

B. Apply compression stockings: Compression stockings help prevent venous thromboembolism and manage edema, but they do not treat muscle spasticity. They offer circulatory support, not neuromuscular control, and therefore would not alleviate the client’s current concern.

C. Give antispasmodic medications: Antispasmodics such as baclofen or tizanidine directly target muscle spasticity by acting on the central nervous system. These medications reduce the frequency and intensity of spasms, improving comfort and mobility in clients with spinal cord injuries.

D. Massage the extremities twice a week: Massage may offer relaxation and temporary relief but is not a primary treatment for spasticity. It does not alter the neurophysiological causes of muscle spasms and is unlikely to produce sustained control over involuntary muscle activity.

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An older adult client is preparing for discharge following a myocardial infarction (MI). The nurse is reviewing the prescribed cardiac diet and exercise instructions with the client. Which action should the nurse implement while teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Chart data is reviewed. Drag from Word Choices to complete the sentence. Client symptoms are indicators of dropdown.

Correct Answer is {"dropdown-group-1":"A"}

Explanation

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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