Nokea
A 92-year-old male client who is independent and lives alone has an inguinal hernia repair. Which teaching method is the best approach to use for his postoperative and discharge instructions?
- A. Written instructions with diagrams.
- B. Verbal instructions with repetition.
- C. Demonstration and return demonstration.
- D. Video instructions with follow-up.
Correct Answer: C
Rationale: Demonstration and return demonstration is the most effective for an elderly client, as it ensures understanding and ability to perform postoperative care tasks, accommodating potential sensory or cognitive limitations.
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The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching?
- A. I should eat a high-protein, high-carbohydrate diet to provide energy.'
- B. It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.'
- C. I should avoid constipation to decrease chances of bleeding.'
- D. If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured.'
Correct Answer: C
Rationale: Avoiding constipation (C) prevents ammonia buildup and bleeding risks. High-protein diets (A) may worsen encephalopathy, acetaminophen (B) is hepatotoxic, and cirrhosis is irreversible (D).
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
- A. Apples.
- B. Tomato juice.
- C. Whole wheat bread.
- D. Beef tenderloin.
Correct Answer: B
Rationale: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
- A. Appearance of cyanosis
- B. Radial pulse
- C. SpO2 of the affected fingers
- D. Blood pressure
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.
To ensure safety for a hospitalized blind client, the nurse should:
- A. Require that the client has a sitter for each shift.
- B. Require that the client stays in bed until the nurse can assist.
- C. Orient the client to the room environment.
- D. Keep the side rails up when the client is alone.
Correct Answer: C
Rationale: Orienting the client to the room environment promotes safety by helping the blind client navigate the space independently and reduce the risk of falls.