Nokea
Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?
- A. "I should provide a regular schedule for toileting."?
- B. "I should talk to my father less because he can't communicate."?
- C. "I should give my father oral care after every meal and bedtime."?
- D. "I should assist my father with eating and drinking."?
Correct Answer: B
Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.
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A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:
- A. Kawasaki disease
- B. rheumatic disease
- C. lupus erythematosus
- D. fifth disease
Correct Answer: D
Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks. Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children. Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.
What are the hazards of improper splinting?
- A. Aggravation of a bone or joint injury
- B. Reduced distal circulation
- C. Delay in transporting a client with a life-threatening injury
- D. All of the above
Correct Answer: D
Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct Answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
- A. The history and presentation might indicate chickenpox, a highly contagious disease.
- B. The lesions might indicate a noncontagious infection that does not require isolation.
- C. The history and presentation might indicate an infectious illness called impetigo.
- D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct Answer: C
Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage. Choice A is incorrect as the presentation is not consistent with chickenpox. Choice B is incorrect because impetigo is contagious, especially through direct contact. Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.
Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. butter
- B. oats or barley cereal
- C. fresh vegetables
- D. coffee or tea
Correct Answer: B
Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.