Nokea
A client diagnosed with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client?
- A. I should use a mouthwash at least once a week.
- B. I should use warm saline or water to rinse my mouth.
- C. I should brush my teeth and rinse my mouth once a day.
- D. Increasing the amount of red meat in my diet will keep this from recurring.
Correct Answer: B
Rationale: To minimize the occurrence of oral thrush in a client with AIDS, maintaining good oral hygiene is essential. Rinsing the mouth with warm saline or water helps keep the oral cavity clean and reduces the risk of Candida overgrowth. Using mouthwash once a week is insufficient, and brushing only once a day does not provide adequate oral hygiene. Increasing red meat intake does not directly affect thrush prevention, as dietary changes unrelated to sugar or carbohydrate reduction have little impact on Candida infections.
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The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client?
- A. Sodium restriction
- B. Increased fat intake
- C. Decreased carbohydrates
- D. Calorie restriction of 1500 daily
Correct Answer: A
Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. The client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000 . The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.
Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?
- A. Maintain a constant connection to low-intermittent suction
- B. Irrigate the tube as per physician's order
- C. Suction the mouth and nose every shift
- D. Perform a daily fecal occult blood sample
Correct Answer: B
Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting. To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (Choice A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (Choice C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (Choice D) is unrelated to maintaining the patency of a nasogastric tube.
While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?
- A. The client is choking on part of the tube
- B. The client has anxiety
- C. The client is having a laryngospasm
- D. The client is having a normal response from anesthesia
Correct Answer: D
Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.
A client is diagnosed with organic erectile dysfunction and the nurse is collecting subjective data from the client. After the assessment, the nurse explains to the client that which are causes of this disorder?
- A. Stress
- B. Depression
- C. Hypertension
- D. Vascular disease
- E. Diabetes mellitus
- F. Alcohol consumption
Correct Answer: C,D,E,F
Rationale: Erectile dysfunction is the inability to achieve or maintain an erection for sexual intercourse. Organic erectile dysfunction is a gradual deterioration of function; the man first notices diminishing firmness and a decrease in frequency of erections. Causes include inflammation of the prostate, urethra, or seminal vesicles; surgical procedures such as prostatectomy; pelvic fractures or lumbosacral injuries; vascular diseases, including hypertension; chronic neurological conditions such as Parkinson's disease or multiple sclerosis; endocrine disorders such as diabetes mellitus or thyroid disorders; smoking and alcohol consumption; drugs; and poor overall health. Functional (not organic) erectile dysfunction usually has a psychological cause.
A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct Answer: D
Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site