Which client statements require follow-up teaching by the nurse? Select all that apply.
“This diagnosis means that I am crazy.”.
“Many people have the same response to a stressful situation as I am having right now.”.
“I will probably need to be on medication for the rest of my life.”.
“I can use holistic approaches like meditation to help my symptoms.”.
“I am at high risk for post-traumatic stress disorder because I have acute stress disorder.”.
“I can learn to manage my thoughts better through therapy.”.
Correct Answer : A,C
Choice A rationale
The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.
Choice B rationale
The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.
Choice C rationale
The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.
Choice D rationale
The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.
Choice E rationale
The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.
Choice F rationale
The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F","H"]
Explanation
H.
Choice A rationale
Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice B rationale
Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.
Choice C rationale
Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.
Choice D rationale
Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.
Choice E rationale
Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.
Choice F rationale
Allowing the client to take a position of comfort can help improve breathing and should be encouraged.
Choice G rationale
Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.
Choice H rationale
Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.
Correct Answer is A
Explanation
Choice A rationale
The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.
Choice B rationale
While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.
Choice C rationale
A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.
Choice D rationale
A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.
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