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A client with a short leg plaster cast reports intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which statement by the client indicates an understanding of the measures used to relieve the itching?
- A. I can use the blunt part of a ruler to scratch the area.
- B. I can trickle small amounts of water down inside the cast.
- C. I need to obtain assistance when placing an object into the cast for the itching.
- D. I can use a hair dryer on the low setting and allow the air to blow into the cast.
Correct Answer: D
Rationale: Itching is a common complaint of clients with casts. Objects should not be put inside a cast because of the risk of scratching the skin and providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with the forceful injection of air inside the cast.
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A 10-year-old child has been diagnosed with type 1 diabetes mellitus. What instruction should the nurse provide concerning the monitoring of the child's insulin needs?
- A. The child should be taught to self-monitor insulin needs.
- B. The parents will need to be available to monitor the child's insulin needs.
- C. The child's school teacher will assume responsibility of insulin need monitoring.
- D. Friends and family will need to be involved with monitoring the child's insulin needs.
Correct Answer: A
Rationale: Most children 9 years old or older can understand the principles of monitoring their own insulin requirements. They are usually responsible enough to determine the appropriate intervention needed to maintain their health. Parents, friends, and family cannot always be available. The school teacher should not be expected to take responsibility for health care interventions.
The nurse is educating the client on how to save lives and prevent burn injuries, in the event of a fire in the home. Which statement by the client indicates that the teaching has been effective?
- A. I should lace escape ladders in the bedrooms.
- B. I should install a whole-house sprinkler system.
- C. I should keep fresh batteries in smoke detectors.
- D. I should mount fire extinguishers in several areas.
Correct Answer: C
Rationale: The early detection of smoke using a smoke detector and immediate evacuation from the house have significant and positive effects on mortality rates. This is because the smoke alarm activates before the appearance of open flames, which gives people in the house a chance to evacuate without burn injuries. Option 1 helps people in the house escape from second-story rooms safely, but it does not alert the people to the fire before flames are evident, thus exposing them to the risk of burn injury. Installing a sprinkler system is very expensive, and this is usually not done in private residences. Fire extinguishers are a good idea to have in the kitchen and other areas for small fires, but they are not designed to extinguish large fires.
Cholestyramine is prescribed, and the nurse provides instructions to the client about the medication. Which client statement indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I need to mix the medication with juice or applesauce.
- C. I should increase my fluid intake while taking this medication.
- D. I should call my primary health care provider immediately if it causes constipation.
Correct Answer: D
Rationale: Common side effects of cholestyramine include constipation, nausea, indigestion, and flatulence. Therefore, it is not necessary to contact the primary health care provider immediately if constipation occurs. Cholestyramine must be administered with food to be effective. This medication should not be taken dry, and it can be mixed in water, juice, carbonated beverages, applesauce, or soup. Increasing fluids will minimize the constipating effects of the medication.
The home care nurse provides instructions about the management of pruritus to a client diagnosed with jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching?
- A. I need to wear loose cotton clothing.
- B. A tepid water bath should help stop the itching.
- C. Keeping the house warmer is likely to lessen the itching
- D. I need to take the prescribed antihistamines as I'm supposed to.
Correct Answer: C
Rationale: Pruritus is caused by the accumulation of bile salts in the skin and results from obstructed biliary excretion. The client would be instructed to keep the house temperature cool in order to minimize the itching. The client should avoid the use of alkaline soap, and he or she (client) should wear loose, soft, cotton clothing. Antihistamines may relieve the itching, as will tepid water and emollient baths.
The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
- A. I need to eat a high-protein diet.
- B. I need to avoid exposure to sunlight.
- C. I need to wash my skin with a mild soap and pat it dry.
- D. I need to apply pressure on the irritated area to prevent bleeding.
Correct Answer: D
Rationale: The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific health care provider instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. The remaining options are accurate measures regarding radiation therapy.