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A home health nurse is assisting a client with planning care for a family member who has Alzheimers disease. Which of the following instructions should the nurse include?
- A. Review the daily schedule with the client every morning.
- B. Limit the clients fluid intake to prevent accidents.
- C. Encourage the client to engage in complex tasks.
- D. Restrict the clients social interactions to reduce confusion.
Correct Answer: A
Rationale: The correct answer is A: Review the daily schedule with the client every morning. This instruction is important for individuals with Alzheimer's disease as it helps provide structure and routine, which can help reduce confusion and anxiety. By reviewing the daily schedule, the client can be prepared for the day's activities, promoting a sense of familiarity and independence.
Option B is incorrect because limiting fluid intake can lead to dehydration and other health issues. Option C is incorrect as individuals with Alzheimer's disease may struggle with complex tasks and may become frustrated. Option D is incorrect because social interactions are important for mental stimulation and emotional well-being, restricting them can lead to increased confusion and isolation.
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A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
- A. Increase your intake of protein to 1 to 1.5 grams per kilogram per day.
- B. Reduce your fluid intake to 1L per day.
- C. Increase sodium intake to prevent hypotension.
- D. Monitor blood glucose levels daily.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of protein to 1 to 1.5 grams per kilogram per day. This is because patients undergoing hemodialysis often experience protein loss during the process. Adequate protein intake helps maintain muscle mass and supports overall health. Option B is incorrect as fluid restriction is typically recommended for patients on hemodialysis due to impaired fluid removal by the kidneys. Option C is incorrect as increasing sodium intake can lead to fluid retention and exacerbate hypertension, a common complication in chronic kidney disease. Option D is not directly related to hemodialysis and is more pertinent to diabetes management.
A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?
- A. Sweating
- B. Increased thirst
- C. Shakiness
- D. Decreased urination
Correct Answer: B
Rationale: Correct Answer: B - Increased thirst
Rationale: Hyperglycemia results in elevated blood glucose levels, which leads to osmotic diuresis and fluid loss, causing increased thirst. Sweating (A) is more commonly associated with hypoglycemia. Shakiness (C) is a symptom of hypoglycemia due to low blood sugar levels. Decreased urination (D) is not a typical manifestation of hyperglycemia as it is more commonly associated with conditions like dehydration or kidney issues.
A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?
- A. Hypertension
- B. Diabetes mellitus
- C. Asthma
- D. Hyperthyroidism
Correct Answer: B
Rationale: The correct answer is B: Diabetes mellitus. Diabetes can lead to increased risk for UTIs due to elevated blood sugar levels creating a favorable environment for bacteria to grow in the urinary tract. High blood sugar weakens the immune system, making it harder to fight infections. Hypertension (A) is a condition related to high blood pressure, not directly associated with UTIs. Asthma (C) and hyperthyroidism (D) are not directly linked to an increased risk for UTIs.
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
- A. Elevated toilet seat
- B. Compression stockings
- C. Heating pad
- D. Nebulizer
Correct Answer: A
Rationale: The correct answer is A: Elevated toilet seat. The nurse should ensure the client has this equipment to facilitate safe and easy toileting post-hip arthroplasty. An elevated toilet seat helps prevent excessive bending at the hip joint, reducing strain and risk of injury. Option B, compression stockings, are used for venous circulation and are not specifically required for hip arthroplasty. Option C, a heating pad, may provide comfort but is not essential for postoperative care. Option D, a nebulizer, is used for respiratory conditions and is not relevant to hip arthroplasty.
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.)
- A. Excessive somnolence
- B. Epistaxis
- C. Pink frothy sputum
- D. Tachypnea
- E. Urinary frequency
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Excessive somnolence (A) can indicate inadequate oxygenation due to pulmonary edema. Pink frothy sputum (C) is a classic sign of pulmonary edema, caused by fluid leaking into the lungs. Tachypnea (D) is the body's response to decreased oxygen levels in the blood, characteristic of pulmonary edema. Epistaxis (B) and urinary frequency (E) are not typically associated with pulmonary edema. In summary, the correct answers reflect respiratory distress and inadequate oxygenation, while the incorrect choices are unrelated symptoms.