When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.)

Apply an allergy identification wrist band.

Instruct the client to avoid medication containing milk and eggs.

Enter allergy information in the client's electronic medical record.

Ensure the client's selections from her dietary menu.

Notify the dietary department of the client's egg intolerance.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.

Choice B: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.

Choice C: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.

Choice D: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.

Choice E: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.

Nursing Test Bank

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

Explanation

Choice A reason: This is incorrect because instructing the client and family to reconsider end of life choices is disrespectful and insensitive. The nurse should respect the client's autonomy and preferences and support their decisions.

Choice B reason: This is correct because teaching the client how to use guided imagery is a helpful intervention for coping with feelings related to death and dying. Guided imagery is a relaxation technique that involves visualizing positive images and scenarios that can reduce stress, anxiety, and pain.

Choice C reason: This is correct because recording the client's desire to live is an important intervention for coping with feelings related to death and dying. The nurse should acknowledge and validate the client's emotions and help them express their hopes and fears.

Choice D reason: This is correct because encouraging family to visit frequently is a beneficial intervention for coping with feelings related to death and dying. The nurse should facilitate family involvement and communication and help the client maintain meaningful relationships.

Choice E reason: This is correct because encouraging family to bring the client old photographs is a useful intervention for coping with feelings related to death and dying. The nurse should assist the client in reminiscing and reviewing their life story and achievements.

A. Think about reasons the episodes occur. B. Center attention on positive upbeat music. C. Practice using muscle relaxation techniques. D. Find outlets for more social interaction.

Correct Answer is C

Explanation

Choice A: Think about reasons the episodes occur. This is not the best instruction, as it may increase the anxiety level of the client. Thinking about reasons may trigger negative thoughts, emotions, or memories that can worsen the anxiety. The nurse should teach the client to focus on coping skills rather than causes.

Choice B: Center attention on positive upbeat music. This is not the best instruction, as it may not be effective for all clients. Listening to positive upbeat music may help distract or soothe some clients, but it may also irritate or annoy others. The nurse should teach the client to choose music that matches their mood and preference.

Choice C: Practice using muscle relaxation techniques. This is the best instruction, as it can reduce the physical symptoms of anxiety. Muscle relaxation techniques involve tensing and relaxing different muscle groups in a systematic way, which can lower blood pressure, heart rate, and breathing rate. The nurse should teach the client how to perform muscle relaxation techniques and practice them regularly.

Choice D: Find outlets for more social interaction. This is not the best instruction, as it may not be feasible or helpful for all clients. Finding outlets for more social interaction may help some clients feel supported or connected, but it may also stress or overwhelm others. The nurse should teach the client to seek social support that is appropriate and comfortable for them.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is providing education to a client who experiences recurrent episodes of moderate anxiety to situations. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

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