Nokea
A client is learning to use a cane. What instruction is essential for this client?
- A. Advance the cane and the weaker leg at the same time
- B. Maintain two points of support on the ground at all times
- C. Use the cane on the weaker side for better support
- D. Advance the cane 30 to 45 cm with each step
Correct Answer: B
Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.
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A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?
- A. Drink 1 liter of water per day.
- B. Take a laxative every morning.
- C. Increase your intake of refined grains.
- D. Walk for at least 30 minutes every day.
Correct Answer: D
Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.
A client with diabetes is being discharged. What is an essential teaching point?
- A. Monitor blood sugar levels once a week
- B. Instruct the client to administer insulin before meals
- C. Teach the client to exercise regularly to maintain glucose control
- D. Administer oral hypoglycemics as needed
Correct Answer: B
Rationale: Instructing the client to administer insulin before meals is a crucial teaching point for a client with diabetes. This action ensures proper glucose management by helping to control blood sugar levels. Monitoring blood sugar levels once a week (Choice A) may not be frequent enough to manage diabetes effectively. While regular exercise (Choice C) is beneficial for glucose control, the immediate administration of insulin is more critical at the time of discharge. Administering oral hypoglycemics as needed (Choice D) is inappropriate as it does not address the need for insulin administration for a client being discharged.
Which lifestyle modification should be emphasized for a client with hypertension?
- A. Increase sodium intake
- B. Reduce caffeine and alcohol intake
- C. Eat carbohydrate-rich meals
- D. Increase protein intake
Correct Answer: B
Rationale: The correct answer is to reduce caffeine and alcohol intake for a client with hypertension. Caffeine and alcohol can increase blood pressure, so reducing their intake can help manage hypertension. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and increased blood pressure. Eating carbohydrate-rich meals (Choice C) is also not ideal as excessive carbohydrates can contribute to weight gain, which can worsen hypertension. Similarly, increasing protein intake (Choice D) is not a primary focus for managing hypertension unless a specific protein deficiency is present.
A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?
- A. Heart rate 80/min
- B. Heart rate 90/min
- C. Respiratory rate 28/min
- D. Heart rate 146/min
Correct Answer: D
Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.
What is the proper technique for measuring blood pressure manually?
- A. Use a stethoscope to listen for the Korotkoff sounds
- B. Ensure the patient is seated with the arm supported
- C. Use a manual sphygmomanometer
- D. Deflate the cuff slowly while listening to the heartbeat
Correct Answer: A
Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.