A client with a history of a burn injury is receiving Hydrotherapy. The nurse should:
- A. Use hot water for cleaning
- B. Apply petroleum-based products
- C. Monitor the water temperature
- D. Cover the wounds with plastic wrap
Correct Answer: C
Rationale: Monitoring water temperature during hydrotherapy prevents further burn injury, ensuring it’s lukewarm. Hot water, petroleum products, and plastic wrap are contraindicated.
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A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:
- A. Avoid heavy lifting
- B. Eat large meals
- C. Sleep flat in bed
- D. Increase spicy food intake
Correct Answer: A
Rationale: Heavy lifting increases abdominal pressure, worsening hiatal hernia symptoms. Small meals, sleeping upright, and avoiding spicy foods are also recommended.
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
- A. I know it was my fault that it happened, because I shouldn't have been out so late.'
- B. If I had not worn that sexy dress that night, he wouldn't have raped me.'
- C. I know my date just had so much passion he couldn't handle me saying 'no.'
- D. I know now that it was not my fault, but I want to continue counseling after my discharge.'
Correct Answer: D
Rationale: The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.
The nurse is teaching a client with a history of osteoporosis about dietary modifications. The nurse should tell the client to increase intake of:
- A. Calcium-rich foods
- B. High-fiber foods
- C. Low-fat foods
- D. High-protein foods
Correct Answer: A
Rationale: Calcium-rich foods strengthen bones and help prevent further bone loss in osteoporosis, a critical dietary modification.
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
- A. Age of the client
- B. Frequency of intercourse
- C. Regularity of the menses
- D. Range of the client's temperature
Correct Answer: C
Rationale: The rhythm method relies on predicting ovulation based on menstrual cycle patterns. Regular menses are essential for accurate prediction. Age intercourse frequency and temperature range are less critical to its success.
A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:
- A. The fetus has not descended into the birth canal.
- B. The fetus is in a transverse lie.
- C. The fetus is level with the ischial spines.
- D. The fetus is at increased risk for precipitate delivery.
Correct Answer: C
Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.
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