Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night.
Which intervention is most important for the nurse to implement?

Ask the spouse if the client seems to be depressed.

Tell the spouse to wait outside so the client can be assessed for depression.

Explain that depression often occurs after a life-threatening experience.

Encourage the client to further describe his feelings.

Answer and Explanation

The Correct Answer is D

A.   Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B.   While privacy is important, the spouse can often provide additional valuable information.
C.   Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D.   Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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Correct Answer is B

Explanation

A. A hard, painless nodule may indicate a deformity but is not an emergency.

B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.

A. The nurse explaining the need for education to the client. B. The client's belief that his needs will be met through education. C. The nurse's empathy about the client having to self-inject. D. The client seeking family approval by agreeing to a teaching plan.

Correct Answer is B

Explanation

A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.

C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Correct Answer is B

Explanation

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is B

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?