The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Engage the client in non-threatening conversations.

Encourage the client's family to visit more often.

Encourage the client to participate in group activities.

Schedule a daily conference with the social worker.

Answer and Explanation

The Correct Answer is A

A. Engage the client in non-threatening conversations: Establishing a therapeutic nurse–client relationship through simple, supportive communication helps reduce isolation, builds trust, and may encourage the client to begin expressing thoughts and feelings.

B. Encourage the client's family to visit more often: Family involvement can be beneficial, but it may not be effective if the client is withdrawn. Increasing visits without first fostering a supportive environment could overwhelm or further isolate the client.

C. Encourage the client to participate in group activities: Group activities promote social interaction but may feel intimidating or threatening for someone who has been withdrawn for weeks. Gradual re-engagement beginning with one-on-one communication is more appropriate.

D. Schedule a daily conference with the social worker: Involving the social worker can be helpful for comprehensive care planning, but this does not directly address the immediate nursing priority of engaging the client therapeutically and reducing withdrawal.

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Correct Answer is ["B","C","D"]

Explanation

A. Duodenal ulcers: There is no direct link between elevated BMI and duodenal ulcers. Ulcers are more commonly associated with H. pylori infection, NSAID use, or stress-related factors rather than obesity.

B. Hyperlipidemia: Obesity is strongly associated with abnormal lipid metabolism, increasing the risk of elevated cholesterol and triglyceride levels. Hyperlipidemia contributes to cardiovascular disease and is a common comorbidity in clients with a BMI ≥30 kg/m².

C. Hypertension: Excess body weight increases vascular resistance and cardiac workload, placing obese clients at higher risk for developing hypertension. Elevated blood pressure is a major obesity-related health concern.

D. Atherosclerosis: Chronic hyperlipidemia and hypertension associated with obesity accelerate plaque formation in arteries. Clients with a high BMI are at increased risk for atherosclerotic cardiovascular disease.

E. Stomatitis: There is no established association between obesity and inflammation of the oral mucosa. Stomatitis is usually related to infections, medications, or nutritional deficiencies.

A. Instruct incentive spirometry use every hour. B. Use petroleum based lotion on skin. C. Administer antibiotics. D. Suggest that client ambulate often. E. Encourage consumption of protein and vitamin C. F. Apply thromboembolism deterrent stockings (TED).

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

Explanation

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

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The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client whose BMI is 35 kg/m². Which condition(s) is/are the client at greatest risk of developing? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

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

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

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The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?