Nokea
A 78-year-old client with diabetes is being taught how to care for his feet. Which statement by the client indicates a need for further education?
- A. I will soak my feet in warm water every day.
- B. I will use a mirror to check my feet every day.
- C. I will apply lotion to my feet every day, avoiding the area between the toes.
- D. I will wear properly fitting shoes at all times.
Correct Answer: A
Rationale: The correct answer is A. Soaking feet daily can lead to excessive moisture, which can increase the risk of skin breakdown or infection in diabetic clients. Choices B, C, and D are all correct statements for foot care in diabetic clients. Using a mirror for daily foot checks helps in early detection of any issues, applying lotion while avoiding the area between the toes helps keep the skin moisturized without creating a risk for fungal infections, and wearing properly fitting shoes is important to prevent pressure points and potential injuries.
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A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?
- A. Encourage the client to drink clear fluids.
- B. Assess the client's skin turgor and mucous membranes.
- C. Monitor the client's vital signs frequently.
- D. Administer an antiemetic as prescribed.
Correct Answer: B
Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.
An older adult client with gastroenteritis has been taking the antidiarrheal diphenoxylate for the past 24 hours. What finding requires the nurse to take further action?
- A. Monitor the client's fluid intake.
- B. Obtain a stool sample for testing.
- C. Administer a laxative to clear the infection.
- D. Assess skin turgor and provide fluids.
Correct Answer: D
Rationale: The correct answer is D. Assessing skin turgor is crucial as tented skin turgor indicates dehydration, which can be worsened by antidiarrheal medications like diphenoxylate. Providing fluids is essential to address dehydration in this client. Monitoring fluid intake (choice A) is important, but assessing skin turgor takes precedence in this situation. Obtaining a stool sample for testing (choice B) could be necessary for diagnostic purposes but is not the immediate priority. Administering a laxative (choice C) is contraindicated in this case as it can worsen the client's condition by further exacerbating fluid loss.
An adolescent with intellectual disability is admitted for refusing to complete oral hygiene. A behavior modification program is recommended. Which reinforcement is best?
- A. Unit tasks for each omitted teeth brushing.
- B. Candy for each successfully completed hygiene task.
- C. Privilege restriction for refusing hygiene tasks.
- D. Preferred activities or tokens for compliance.
Correct Answer: D
Rationale: The best reinforcement strategy in this scenario is providing preferred activities or tokens for compliance. Positive reinforcement is effective in behavior modification programs for individuals with intellectual disabilities. Offering preferred activities or tokens serves as a reward for completing the desired behavior, in this case, oral hygiene tasks. Choices A, B, and C do not focus on reinforcing the desired behavior with positive incentives. Choice A does not provide a positive reinforcement for compliance but rather focuses on the omission of a task. Choice B uses candy, which may not be ideal for oral hygiene. Choice C involves punishment rather than positive reinforcement.
The nurse is preparing a client who had a BKA amputation for discharge to home. Which recommendations should the nurse provide this client?
- A. All of the above
- B. Inspect the skin for redness
- C. Use a residual limb shrinker
- D. Wash the stump with soap and water
Correct Answer: A
Rationale: Proper care of the residual limb is essential in preventing complications like infection or poor healing. By choosing 'All of the above,' the nurse ensures that the client receives comprehensive care. Inspecting the skin for redness is crucial as it can help in early detection of infections. Using a residual limb shrinker helps reduce swelling and maintain proper shaping of the limb. Washing the stump with soap and water on a daily basis is important for hygiene and preventing infections. Therefore, all the recommendations (choices A, B, and C) are essential for the client's care, making choice A the correct answer. Choice D is incorrect as it does not encompass all the necessary recommendations for the client's care.
A client with chronic liver disease is prescribed lactulose. Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?
- A. Bilirubin level
- B. Serum ammonia level
- C. Serum potassium level
- D. Albumin level
Correct Answer: B
Rationale: The correct answer is B: Serum ammonia level. Lactulose is used to lower serum ammonia levels in clients with chronic liver disease, particularly in cases of hepatic encephalopathy. Monitoring serum ammonia levels is crucial to evaluate the effectiveness of lactulose in managing hepatic encephalopathy. Choices A, C, and D are incorrect because they are not directly related to the action or evaluation of lactulose in chronic liver disease.