Nokea
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
- A. Adhering to a strict schedule of diet, exercise, and wound care
- B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- D. Allowing him to plan, assist in, and perform his own care whenever possible
Correct Answer: D
Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
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A client with a history of ulcerative colitis is admitted with complaints of bloody diarrhea. The nurse should give priority to:
- A. Monitoring for dehydration
- B. Administering pain medication
- C. Preparing for surgery
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Bloody diarrhea in ulcerative colitis can cause significant fluid and electrolyte loss, so monitoring for dehydration is the priority.
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Lactose-restricted diet
- B. Gluten-restricted diet
- C. Phenylalanine-restricted diet
- D. Fat-restricted diet
Correct Answer: B
Rationale: A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. A gluten-restricted diet is the diet for children with celiac disease. A phenylalanine-restricted diet is prescribed for children with phenylketonuria. A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn't that a lot?' The nurse's best response is:
- A. Yes, that does seem like a lot.'
- B. You'll have to talk to the doctor about that. The physician knows what's best for the client.'
- C. Six to 10 treatments are common. Are you concerned about permanent effects?'
- D. Don't worry. Some clients have lots more than that.'
Correct Answer: C
Rationale: The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communication with the husband to identify underlying fears and knowledge deficits.
A client with a history of a stroke is being taught to use a quad cane. The nurse should teach the client to:
- A. Hold the cane in the strong hand
- B. Advance the cane with the strong leg
- C. Use the cane on the weak side
- D. Lean heavily on the cane
Correct Answer: C
Rationale: The quad cane should be used on the weak side to support the affected leg post-stroke, improving balance. Holding in the strong hand or advancing with the strong leg is incorrect.
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.