Nokea
A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?
- A. Teaching the client to feel for reddened areas
- B. Asking a family member to assess the skin daily
- C. Teaching the client to use a mirror for skin assessment
- D. Scheduling the client to return to the clinic daily for a skin check
Correct Answer: C
Rationale: The client should be encouraged to be as independent as possible. The most effective means of skin self-assessment for this client is with the use of a mirror. The redness cannot be felt. Asking a family member to assess the skin daily does not promote independence. It is unnecessary and unrealistic for the client to return to the clinic daily for a skin check.
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A client diagnosed with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for what period of time?
- A. 1 week
- B. 24 hours
- C. 5 to 7 days
- D. 2 to 3 weeks
Correct Answer: D
Rationale: Levodopa takes 2 to 3 weeks to show results in Parkinson's disease, as it gradually increases dopamine levels to alleviate symptoms. Shorter time frames (24 hours, 5 to 7 days, 1 week) are unrealistic for noticeable improvement.
The home-care nurse visits an older client diagnosed with Parkinson's disease who requires instillation of multiple eye drops. Which instruction for the administration of eye drops should the nurse plan to provide to this client who demonstrates signs/symptoms of this diagnosis?
- A. Administer the eye drops rapidly.
- B. Have a family member instill the eye drops.
- C. Lie down on a bed or sofa to instill the eye drops.
- D. Keep the eye drops in the refrigerator so that they will thicken.
Correct Answer: C
Rationale: Older adults diagnosed with Parkinson's disease will experience tremors, making it more difficult to instill eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops to provide control and allow the drops to be administered more easily. If multiple eye drops are needed, there should be a wait time of 3 to 4 minutes between drops. It is unreasonable to expect a family member to be available consistently to instill the eye drops. Additionally, this discourages client independence. Placing the eye drops in the refrigerator should not be done unless specifically prescribed.
The school nurse teaches an athletic coach how to prevent dehydration among athletes practicing in the hot weather. What is the best advice for the nurse to give to the coach?
- A. Drink plenty of fluids before and after practice.
- B. Have the athletes take a salt tablet before practice.
- C. Reschedule practice for before school and after sunset.
- D. Provide a fluid break every 30 minutes during practice.
Correct Answer: D
Rationale: Hot weather accelerates the body's loss of fluid and electrolytes during strenuous physical activity, so the nurse encourages the coach to schedule fluid breaks at 30-minute intervals so that the athletes can periodically rest and restore body fluids. Drinking fluid before and after practice is a reasonable suggestion; however, because the hot weather accelerates fluid and electrolyte losses, body fluids must be periodically replenished to maintain the fluid and electrolyte balance. Although a sodium load increases fluid retention, the nurse avoids suggesting salt tablets for the athletes because the nurse needs approval from each athlete's primary health care provider before recommending the salt. Rescheduling practice times is unrealistic.
The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding?
- A. A normal value that indicates that the client is managing blood glucose control well
- B. A value that does not offer information regarding the client's management of the disease
- C. A low value that indicates that the client is not managing blood glucose control very well
- D. A high value that indicates that the client is not managing blood glucose control very well
Correct Answer: D
Rationale: Glycosylated hemoglobin is a measure of glucose control during the 6 to 8 weeks before the test. It is a reliable measure for determining the degree of glucose control in diabetic clients over a period of time, and it is not influenced by dietary management 1 to 2 days before the test is done. The glycosylated hemoglobin level should be 6.0% or less for a client diagnosed with diabetes mellitus, with elevated levels indicating poor glucose control.
A client being discharged to home after angioplasty via the right femoral groin has received the catheter insertion site discharge instructions from the nurse. Which client statement indicates that the client understands the instructions?
- A. Coolness or discoloration of the right foot is expected.
- B. I should expect a large area of bruising at the right groin.
- C. Temperature as high as 101°F (38.3°C) is not unusual a few days after the procedure.
- D. Mild discomfort in the right groin may occur, and Tylenol should relieve the pain.
Correct Answer: D
Rationale: The client may feel some mild discomfort at the catheter insertion site after angioplasty. This is usually relieved by analgesics such as acetaminophen (Tylenol). The client is taught to report to the primary health care provider any neurovascular changes to the affected leg; bleeding or bruising at the insertion site; and signs/symptoms of local infection, such as drainage at the site or increased temperature.