Nokea
A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?
- A. ''I need to avoid foods high in vitamin C.''
- B. ''I should eat a consistent amount of vitamin K each day.''
- C. ''I can eat as many leafy greens as I want.''
- D. ''I should not worry about any changes in my diet.''
Correct Answer: B
Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.
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The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, "What do you think you're doing?" How should the nurse respond?
- A. "I cannot give you this medication until you calm down."
- B. "This shot will help relieve the pain in your feet."
- C. "Would you prefer to learn to administer your own shot?"
- D. "You will feel calmer and less jittery after this shot."
Correct Answer: B
Rationale: The correct response is to provide a relevant explanation to the client. Choice B, "This shot will help relieve the pain in your feet," is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.
While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client's serum laboratory values?
- A. Potassium
- B. Platelets
- C. Creatinine
- D. Albumin
Correct Answer: D
Rationale: The correct answer is D: Albumin. Reviewing albumin levels is crucial in this situation because low albumin levels can impact wound healing and contribute to increased wound edges. Potassium (choice A) is not directly related to wound healing or wound edges. Platelets (choice B) are more related to blood clotting than wound healing. Creatinine (choice C) is related to kidney function, not specifically to wound healing or wound edges.
When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?
- A. Wash hands frequently
- B. Avoid drinking lake water
- C. Wear long sleeves and pants
- D. Do not share personal products
Correct Answer: C
Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
- A. Children usually resume their toileting behaviors when they leave the hospital
- B. A retraining program will need to be initiated when the child returns home
- C. Diapering will be provided since hospitalization is stressful to preschoolers
- D. A potty chair should be brought from home so he can maintain his toileting skills
Correct Answer: A
Rationale: Children often regress in toileting behaviors during hospitalization due to stress and changes in routine. However, they usually resume normal behaviors once they are discharged and back in their familiar environment. Providing reassurance to the parents that the child is likely to return to his previous toileting habits after leaving the hospital can help alleviate their concerns. Choices B, C, and D are incorrect because they do not address the normal pattern of behavior regression and recovery in toileting skills associated with hospitalization.
When gathering subjective data from a client, what intervention should the nurse implement first?
- A. Listen attentively
- B. Establish rapport
- C. List problems
- D. Clarify inferences
Correct Answer: B
Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.