Nokea
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.
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What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a barrel chest, which is often associated with chronic breathing problems like chronic obstructive pulmonary disease (COPD). Chronic breathing problems can lead to this specific chest shape due to increased lung volume. Choice A is incorrect as it does not directly relate to the physical assessment findings. Choice C is incorrect as it focuses on exercise habits rather than the client's current health status. Choice D is incorrect as it does not address the potential underlying health issue indicated by the chest measurements.
A patient with end-stage liver failure tells the nurse, “If I can just live to see my first grandchild who is expected in 5 months, then I can die happy.” The nurse recognizes that the patient is demonstrating which of the following stages of grieving?
- A. Prolonged grief disorder
- B. Kübler-Ross’s stage of bargaining
- C. Kübler-Ross’s stage of depression
- D. The new normal stage of the Grief Wheel.
Correct Answer: B
Rationale: The patient is expressing a desire to delay death in exchange for a significant event, characteristic of the bargaining stage in Kübler-Ross's model of grief.
You are reviewing the drug list of an elderly client who is on several medications prescribed by different specialists for various health problems. The client reports 'lately there has been a roaring sound in my ears.' You notify the prescriber of which medication?
- A. gentamicin sulfate (Garamycin)
- B. metoprolol (Lopressor)
- C. amoxicillin (Amoxil)
- D. warfarin (Coumadin)
Correct Answer: A
Rationale: Gentamicin is an ototoxic medication that can cause tinnitus or hearing loss, warranting notification of the prescriber.
For Mr. Jones’ persistent productive cough, what nursing action would be most appropriate?
- A. Increase intake of warm liquids
- B. Administer narcotic cough medication
- C. Monitor the amount of sputum produced each day
- D. Place the patient on strict bed rest
Correct Answer: A
Rationale: Warm liquids soothe the throat and thin mucus, facilitating expectoration.
Which of the following are the treatments of a non-severe sty?
- A. Cold compresses
- B. Warm soaks
- C. Limited sensory stimulation
- D. Incision and drainage
Correct Answer: B
Rationale: Warm soaks help reduce inflammation and promote healing of a non-severe sty.