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A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?
- A. Monitor the client's blood glucose level.
- B. Encourage the client to increase fluid intake.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct Answer: A
Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.
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A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?
- A. Cough deeply after each use.
- B. Take a deep breath and hold for 10 seconds.
- C. Breathe in slowly and deeply to raise the ball or piston.
- D. Exhale forcefully before using the spirometer.
Correct Answer: C
Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.
A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Acupuncture
- B. Massage therapy
- C. Aromatherapy
- D. Herbal supplements
Correct Answer: A
Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
- A. Educating clients about the recommended immunization schedule for adults
- B. Teaching clients how to manage chronic illnesses
- C. Providing counseling for depression
- D. Offering support groups for cancer survivors
Correct Answer: A
Rationale: The correct answer is A: Educating clients about the recommended immunization schedule for adults. This activity falls under primary prevention, which aims to prevent the onset of illness or injury. Immunizations are a proactive measure to protect individuals from developing certain diseases. Choices B, C, and D involve managing chronic illnesses, providing counseling for mental health issues, and offering support for individuals who have already experienced cancer, respectively. These activities are more aligned with secondary or tertiary prevention, focusing on managing existing conditions or preventing complications in those already affected.
A client who is postoperative has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
- A. Absent bowel sounds with distention
- B. Hyperactive bowel sounds with pain
- C. Normal bowel sounds with cramping
- D. Diminished bowel sounds with tenderness
Correct Answer: A
Rationale: Paralytic ileus is a condition where there is a temporary paralysis of the bowel, leading to absent bowel sounds and abdominal distention. This occurs because the bowel is not functioning properly to propel contents, resulting in a lack of bowel sounds. Absent bowel sounds with distention are typical findings in paralytic ileus. Hyperactive bowel sounds with pain are more indicative of increased motility and are not expected in paralytic ileus. Normal bowel sounds with cramping may be seen in other conditions, such as gastroenteritis. Diminished bowel sounds with tenderness are not typical findings in paralytic ileus.
The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. Which action should the nurse implement?
- A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
- B. Ensure that the UAP has placed pillows effectively to protect the client
- C. Ask the UAP to use some pillows to prop the client in a side-lying position
- D. Assume responsibility for placing the pillows while the UAP completes another task
Correct Answer: A
Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.