Nokea
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
- A. Encourage the use of corrective lenses during the day
- B. Practice visual exercises that focus on a still object
- C. Alternate an eye patch from eye every 2 hours
- D. Teach techniques for scanning the environment
Correct Answer: D
Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.
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A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)
- A. Sausage patties and eggs
- B. Whole wheat toast and jam
- C. Bagels and cream cheese
- D. Blackberries and oatmeal
Correct Answer: B
Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.
A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?
- A. Cleanse the site around the catheter
- B. Use a 20 ml syringe to deflate balloon
- C. Clamp catheter until the client voids naturally
- D. Empty urine from the urinary drainage bag
Correct Answer: B
Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.
A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?
- A. Digitally check the client for a fecal impaction
- B. Increase fluid intake to promote bowel regularity
- C. Provide a high-fiber diet to facilitate bowel movements
- D. Administer a stool softener
Correct Answer: A
Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.
When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?
- A. Administer antianxiety medication before providing discharge instructions
- B. Schedule a follow-up appointment for an outpatient psychosocial assessment
- C. Obtain a blood cortisol level before discharge
- D. Encourage the client to remain in the hospital for a few more days
Correct Answer: B
Rationale: The correct intervention is to schedule a follow-up appointment for an outpatient psychosocial assessment. This option addresses the client's concerns and provides support for managing stress and preventing future crises, which is crucial for the client's long-term care. Administering antianxiety medication before providing discharge instructions (Choice A) may not effectively address the underlying concerns. Obtaining a blood cortisol level before discharge (Choice C) is important but not the priority in this situation. Encouraging the client to remain in the hospital for a few more days (Choice D) is not the best course of action as it may not address the client's anxiety and could potentially lead to other issues.
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
- A. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete
- B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
- C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
- D. Notify the nurse when the transfusion has finished, so further client assessment can be done
Correct Answer: A
Rationale: The correct instruction for the UAP is to continue measuring the client's vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.