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A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse include?
- A. Strategies to manage memory loss and confusion.
- B. Instructions to limit physical activity to prevent falls.
- C. The need for a low-protein diet to reduce metabolic stress.
- D. The importance of avoiding all medications that affect the brain.
Correct Answer: A
Rationale: Multi-infarct dementia involves memory loss and confusion due to multiple small strokes. Teaching strategies to manage these symptoms, such as memory aids and structured routines, is essential for supporting the client and family.
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The school nurse planning to give a class on testicular self-examination (TSE) at a local high school should include which instruction to the participants?
- A. Perform the self-examination every other month.
- B. Perform the self-examination after a cold shower.
- C. Expect the self-examination to be slightly painful.
- D. Roll the testicle between the thumb and forefinger.
Correct Answer: D
Rationale: TSE is a self-screening examination for testicular cancer, which predominantly affects men in their late teens and twenties. The self-examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. The self-examination should not be painful. It is easiest to do either during or after a warm shower (or bath) when the scrotum is relaxed.
A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin level is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and his family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the physician and family to next:
- A. Discontinue all measures.
- B. Notify the hospital attorney.
- C. Attempt to stabilize the client through the use of fluid replacement.
- D. Give enough blood to keep the client from dying.
Correct Answer: C
Rationale: Respecting the client's religious beliefs, the nurse should focus on stabilizing the client with fluid replacement to address hypovolemia, as blood transfusions are refused.
Which of these case management methods employs the intrinsic use of multidisciplinary plans of care that are based on the client's current condition, and reflect interventions and expected outcomes within a pre-established time line?
- A. The Case Manager Model
- B. The ProACT Model
- C. The Collaborative Practice Model
- D. The Triad Model of Case Management
Correct Answer: D
Rationale: The Triad Model of Case Management uses multidisciplinary plans of care based on the client's current condition, with interventions and expected outcomes within a pre-established timeline, involving collaboration among nursing, social work, and utilization review teams.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
A client with a history of chronic kidney disease is prescribed calcium carbonate (Tums). The nurse should instruct the client to:
- A. Take the medication between meals.
- B. Take the medication with meals.
- C. Avoid taking the medication with dairy products.
- D. Stop the medication if constipation occurs.
Correct Answer: B
Rationale: Calcium carbonate should be taken with meals to bind phosphate in the gut, managing hyperphosphatemia in kidney disease.