Nokea
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
You may also like to solve these questions
The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
- A. Surgery
- B. Bladder retraining
- C. Scheduled toileting
- D. Dietary modifications
- E. Pelvic muscle exercises
- F. Intermittent catheterization
Correct Answer: B,C,D,E
Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply.
- A. Pain level
- B. Vital signs
- C. Hourly urine output
- D. Tolerance for sips of clear liquids
- E. Ability to cough and deep breathe
Correct Answer: A,B,C,E
Rationale: After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs, pain level, and ability to cough and deep breathe. Clear liquids are not given until the client has bowel sounds.
A hepatitis B screen is performed on a postpartum client and the results indicate the presence of antigens in the maternal blood. Which intervention should the nurse anticipate to be prescribed for the neonate? Select all that apply.
- A. Obtaining serum liver enzymes
- B. Administering hepatitis vaccine
- C. Supporting breastfeeding every 5 hours
- D. Repeating hepatitis B screen in 1 week
- E. Administering hepatitis B immune globulin
- F. Administering antibiotics while hospitalized
Correct Answer: B,E
Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the neonate should receive the hepatitis vaccine and hepatitis B immune globulin within 12 hours after birth. Obtaining serum liver enzymes, retesting the maternal blood in a week, breastfeeding every 5 hours, and administering antibiotics are inappropriate actions and would not decrease the chance of the neonate contracting the hepatitis B virus.
A client diagnosed with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper care of the skin over the treatment field when the client makes which statement?
- A. I'll be able to wash the ink marks off my skin after the initial treatment.
- B. Direct sunlight is something I'll have to really avoid exposing my skin to.
- C. I'll have my family bring me some unscented lotion to keep my skin soft.
- D. Wearing snug fitting clothing over the skin site will help provide good support.
Correct Answer: B
Rationale: The client undergoing radiation therapy must keep the affected skin protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools). The client should wash the site using mild soap and warm or cool water and pat the area dry. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. No lotions, creams, alcohol, perfumes, or deodorants should be placed on the skin over the treatment site. The client should wear cotton clothing over the skin site and guard against irritation from tight or rough clothing such as belts or bras.