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Client Statement

Exhibits

The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.

I purchased a large magnifying glass.

I’m adding bananas to my oatmeal every morning.

Instead of being barefoot, I wear socks.

I moved my medicine bottles into the living room.

I switched to eating apples and oranges for a nighttime snack.

I placed a lamp on my bedside table.

I prepared a large batch of beans, so I have a fast meal every night.

I added a nonslip throw rug at my kitchen sink.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Choice A Reason:

The client states, “I purchased a large magnifying glass.” While this shows an attempt to address the issue of blurred vision, it does not fully address the safety concerns related to macular degeneration. The client should be encouraged to use additional visual aids, such as better lighting and possibly electronic magnifiers, to ensure they can see clearly and avoid accidents. Therefore, this statement indicates that the client needs further teaching.

Choice B Reason:

The client states, “I’m adding bananas to my oatmeal every morning.” This is a positive dietary change. Bananas are rich in potassium, which can help manage blood pressure, a crucial aspect for someone with hypertension. Additionally, adding fruit to breakfast can improve overall nutrition. Therefore, this statement indicates that the client understood the teaching.

Choice C Reason:

The client states, “Instead of being barefoot, I wear socks.” While wearing socks is better than being barefoot, it is not the safest option. Socks can still be slippery on certain surfaces, increasing the risk of falls. The client should be encouraged to wear non-slip shoes or slippers inside the house. Therefore, this statement indicates that the client needs further teaching.

Choice D Reason:

The client states, “I moved my medicine bottles into the living room.” While this might make the medications more accessible, it is not the safest practice. Medications should be stored in a cool, dry place, away from direct sunlight and moisture. Additionally, they should be kept in a location where they are easily visible and accessible but not in a high-traffic area where they could be knocked over. Therefore, this statement indicates that the client needs further teaching.

Choice E Reason:

The client states, “I switched to eating apples and oranges for a nighttime snack.” This is a positive dietary change. Apples and oranges are rich in vitamins and fiber, which are beneficial for overall health. This change also indicates an understanding of the need to incorporate more fruits into the diet. Therefore, this statement indicates that the client understood the teaching.

Choice F Reason:

The client states, “I placed a lamp on my bedside table.” This is a good practice as it ensures that the client has adequate lighting when getting in and out of bed, reducing the risk of falls. Therefore, this statement indicates that the client understood the teaching.

Choice G Reason:

The client states, “I prepared a large batch of beans, so I have a fast meal every night.” This is a positive change as it ensures that the client has a nutritious meal readily available, reducing the reliance on processed frozen meals. Beans are a good source of protein and fiber, which are important for overall health. Therefore, this statement indicates that the client understood the teaching.

Choice H Reason:

The client states, “I added a nonslip throw rug at my kitchen sink.” While the intention is good, throw rugs can still pose a tripping hazard, even if they are nonslip. It would be safer to use a mat that is securely fixed to the floor. Therefore, this statement indicates that the client needs further teaching.

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Correct Answer is C

Explanation

Choice A reason: Veracity

Veracity refers to the ethical principle of truthfulness and honesty. In the context of nursing, it involves providing accurate and complete information to patients. While veracity is crucial in maintaining trust between the nurse and the patient, it is not directly related to the decision to discontinue a medication due to adverse effects.

Choice B reason: Fidelity

Fidelity involves being faithful to commitments and promises made to patients. It includes maintaining confidentiality and being loyal to the patient’s best interests. Although fidelity is important in the nurse-patient relationship, it does not specifically address the ethical considerations involved in discontinuing a harmful medication.

Choice C reason: Nonmaleficence

Nonmaleficence is the ethical principle of doing no harm. In this scenario, discontinuing the experimental chemotherapy medication due to evidence of rapidly advancing kidney failure aligns with the principle of nonmaleficence. The nurse and healthcare team are acting to prevent further harm to the patient by stopping a treatment that is causing significant adverse effects.

Choice D reason: Autonomy

Autonomy refers to respecting the patient’s right to make their own decisions about their healthcare. This includes providing the patient with all necessary information to make informed choices. While autonomy is a fundamental ethical principle, the decision to discontinue the medication in this case is primarily based on preventing harm, which aligns more closely with nonmaleficence.

A. Intense pruritus B. Irregular borders C. Uniform pigmentation D. Purulent drainage

Correct Answer is B

Explanation

Choice A reason:

Intense pruritus: While itching (pruritus) can be a symptom of skin conditions, it is not a definitive sign of malignancy in nevi. Pruritus can be associated with benign conditions such as eczema or allergic reactions. However, if a mole starts to itch, it should be monitored closely, but it is not as strong an indicator of malignancy as irregular borders.

Choice B reason:

Irregular borders: This is a significant sign of potential malignancy in nevi. Melanomas often have uneven, notched, or scalloped borders, unlike benign moles, which typically have smooth, even borders. The irregularity in the border is due to the uncontrolled growth of melanocytes, which can spread unevenly.

Choice C reason:

Uniform pigmentation: Uniform pigmentation is generally a sign of a benign mole. Malignant moles often have multiple colors or an uneven distribution of color, which can include shades of brown, black, red, white, or blue. A mole with uniform color is less likely to be malignant.

Choice D reason:

Purulent drainage: While purulent drainage (pus) indicates an infection, it is not a typical sign of malignancy in nevi. Infections can occur in any skin lesion, but they do not specifically indicate cancer. Malignant moles are more likely to change in size, shape, or color rather than produce pus.

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Client Statement Exhibits The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?

A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?

Client Statement

Exhibits

The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.