An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?
Reinforce need for adequate hydration.
Provide typed instructions for healthy diet selection.
Schedule follow-up appointments with specialists.
Demonstrate specific breathing and walking exercises.
The Correct Answer is C
Choice A reason: Reinforcing need for adequate hydration is not the most important action for the nurse to implement, as this is a general recommendation for all clients and does not address the specific needs of this client. This is a distractor choice.
Choice B reason: Providing typed instructions for healthy diet selection is not the most important action for the nurse to implement, as this may not be feasible or accessible for this client who lives in a poor neighborhood and may have limited resources and literacy. This is another distractor choice.
Choice C reason: Scheduling follow-up appointments with specialists is the most important action for the nurse to implement, as this can ensure that this client receives continuous and comprehensive care for their complex and chronic conditions, which can improve their outcomes and quality of life. Therefore, this is the correct choice.
Choice D reason: Demonstrating specific breathing and walking exercises is not the most important action for the nurse to implement, as this can be done by other health care professionals or at home by the client. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.
Choice B reason: A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby does not require the nurse's immediate attention. Bipolar disorder is a mood disorder that causes alternating episodes of mania and depression. Pacing around the lobby may indicate restlessness, agitation, or increased energy, which are common signs of mania. The nurse should monitor the client's behavior and mood and ensure safety and appropriate medication administration.
Choice C reason: This is the correct answer because an 18-year-old client with antisocial behavior who is being yelled at by other clients requires the nurse's immediate attention. Antisocial behavior is a pattern of disregard for and violation of the rights of others. Being yelled at by other clients may indicate conflict, aggression, or provocation, which are common features of antisocial behavior. The nurse should intervene to de-escalate the situation and prevent violence or harm.
Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.
Correct Answer is C
Explanation
Choice A reason: Straining all urine is not a relevant instruction for the nurse to provide, as this is not related to prostatitis. This is a distractor choice.
Choice B reason: Maintaining contact isolation is not a necessary instruction for the nurse to provide, as prostatitis is not a contagious condition. This is another distractor choice.
Choice C reason: Avoiding urinary catheterization is an important instruction for the nurse to provide, as this can introduce bacteria into the urinary tract and worsen the infection. Therefore, this is the correct choice.
Choice D reason: Restricting oral fluid intake is not an appropriate instruction for the nurse to provide, as this can lead to dehydration and reduced urine output, which can increase the risk of urinary stasis and infection. This is another distractor choice.
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