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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 A

Explanation

Choice A reason:

Place a black tag on the client’s upper body and attempt to help the next client in need: In mass casualty incidents, triage is used to prioritize treatment based on the severity of injuries and the likelihood of survival. A black tag indicates that the victim is deceased or has injuries that are not compatible with life and that resources should be directed to those who have a better chance of survival. Since the client remains apneic even after repositioning the airway, it indicates that they are not breathing and have a very low chance of survival.

Choice B reason:

Reposition the client’s upper airway a second time before assessing his respirations: While ensuring the airway is open is crucial, if the client remains apneic after the initial repositioning, further attempts are unlikely to be successful in a mass casualty scenario where time and resources are limited2. The priority is to move on to other victims who may have a higher chance of survival.

Choice C reason:

Start CPR: In a mass casualty situation, CPR is typically not initiated for victims who are apneic and pulseless due to the need to allocate resources to those who have a higher likelihood of survival3. The focus is on providing immediate care to those who can benefit the most from it.

Choice D reason:

Place a red tag on the client’s upper body and obtain immediate help from other personnel: A red tag is used for victims who require immediate life-saving interventions and have a high chance of survival if treated promptly4. Since the client is apneic and remains so after airway repositioning, they do not meet the criteria for a red tag.

A. Vesicles on the skin B. Respiratory failure C. Flu-like symptoms D. Coughing of blood

Correct Answer is B

Explanation

Choice A Reason:

Vesicles on the skin are more commonly associated with cutaneous anthrax, not inhalation anthrax. Cutaneous anthrax typically presents with a raised, itchy bump that develops into a painless sore with a black center.

Choice B Reason:

Respiratory failure is a severe and common symptom of inhalation anthrax. Inhalation anthrax begins with flu-like symptoms but can rapidly progress to severe respiratory distress, shock, and often death if not treated promptly.

Choice C Reason:

Flu-like symptoms are indeed an early sign of inhalation anthrax, but they are not specific enough to indicate exposure definitively. These symptoms include sore throat, mild fever, fatigue, and muscle aches.

Choice D Reason:

Coughing of blood can occur in the later stages of inhalation anthrax as the disease progresses and the respiratory system becomes severely compromised.

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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

A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

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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.