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A client with hypertension is receiving dietary education from a nurse. Which recommendation should the nurse include?
- A. Increase your intake of saturated fats.
- B. Limit your sodium intake to less than 2 grams per day.
- C. Avoid foods high in potassium.
- D. Consume at least three alcoholic beverages daily.
Correct Answer: B
Rationale: The correct answer is B: Limit your sodium intake to less than 2 grams per day. Sodium restriction is crucial in managing hypertension as it helps reduce blood pressure. Excessive sodium intake can lead to fluid retention and increased blood volume, worsening hypertension. This recommendation aligns with evidence-based guidelines for hypertension management.
Incorrect choices:
A: Increasing saturated fat intake is not recommended for hypertension, as it can lead to cardiovascular issues.
C: Avoiding foods high in potassium is not advised, as potassium helps regulate blood pressure.
D: Consuming alcoholic beverages daily can raise blood pressure and interfere with hypertension management.
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A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which instruction should the nurse include in the client's discharge teaching?
- A. Report any signs of infection, such as sore throat or fever, to your healthcare provider.'
- B. Increase your intake of iodine-rich foods, such as seafood and dairy products.'
- C. Take the medication on an empty stomach for better absorption.'
- D. You may experience weight gain and fatigue as side effects of the medication.'
Correct Answer: A
Rationale: The correct answer is A: "Report any signs of infection, such as sore throat or fever, to your healthcare provider." This is important because PTU can cause agranulocytosis, a serious side effect that can lead to severe infections. By reporting signs of infection early, the healthcare provider can monitor the client's blood counts and adjust treatment if necessary.
Choice B is incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism. Choice C is incorrect because PTU should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because weight gain and fatigue are not common side effects of PTU; in fact, weight loss and hyperactivity are more common.
A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?
- A. Serum glucose of 350 mg/dL.
- B. Serum potassium of 2.8 mEq/L.
- C. Serum sodium of 136 mEq/L.
- D. Serum bicarbonate of 20 mEq/L.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 2.8 mEq/L. Hypokalemia can lead to life-threatening cardiac arrhythmias, especially in diabetic patients with hyperglycemia. Immediate intervention is needed to prevent cardiac complications.
A: Serum glucose of 350 mg/dL is high but not immediately life-threatening.
C: Serum sodium of 136 mEq/L is within normal range and does not require immediate intervention.
D: Serum bicarbonate of 20 mEq/L is slightly low but does not pose an immediate risk to the patient's life.
A client with hypothyroidism is prescribed levothyroxine (Synthroid). Which instruction should the nurse provide?
- A. Take the medication with a meal.
- B. Take the medication at bedtime.
- C. Take the medication on an empty stomach.
- D. Take the medication with an antacid.
Correct Answer: C
Rationale: The correct answer is C: Take the medication on an empty stomach. Levothyroxine should be taken on an empty stomach in the morning, at least 30 minutes before eating, to ensure optimal absorption. Food can interfere with the absorption of levothyroxine, reducing its effectiveness. Taking it with a meal (option A) or at bedtime (option B) may lead to decreased absorption. Taking it with an antacid (option D) can also interfere with absorption. Therefore, the best instruction is to take the medication on an empty stomach to maximize its therapeutic effects.
An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
- A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
- B. The UAP should be reassigned to another group of residents, preferably females only.
- C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
- D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct Answer: C
Rationale: The correct answer is C because the behavior exhibited by the resident may stem from touch deprivation rather than being intentional sexual harassment. Here's a step-by-step rationale:
1. Understanding the resident's age and environment (extended care facility) helps in interpreting his behavior.
2. The resident's actions suggest a need for touch, which is common in older adults who may lack physical contact.
3. Educating the resident on appropriate ways to express his need for touch can address the underlying issue.
4. Reassigning the UAP or reporting the incident as sexual harassment (options A and B) may not address the root cause of the behavior and could potentially harm the resident's well-being.
In summary, choice C focuses on addressing the resident's potential touch deprivation in a compassionate and understanding manner, making it the best assessment of the situation.
A client with chronic pain is prescribed a fentanyl (Duragesic) patch. Which instruction should the nurse provide to the client?
- A. Apply the patch to a clean, dry, and hairless area of the skin.
- B. Use a heating pad over the patch to enhance absorption.
- C. Change the patch daily to maintain effectiveness.
- D. Place the patch on the same site with each application.
Correct Answer: A
Rationale: The correct answer is A. Applying the fentanyl patch to a clean, dry, and hairless area of the skin ensures proper absorption and effectiveness. Moisture, oils, and hair can interfere with absorption. Option B is incorrect as heating pads can increase drug absorption and lead to overdose. Option C is incorrect because fentanyl patches are usually changed every 72 hours, not daily. Option D is incorrect because rotating application sites helps prevent skin irritation and tolerance development.