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A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. The client reports his feet feel uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?
- A. Use a bed cradle to hold the covers off feet.
- B. Provide a warming pad (Aqua-pad or K-pad) to feet.
- C. Place warm blankets next to the client's feet.
- D. Medicate the client with a prescribed sedative.
Correct Answer: B
Rationale: A warming pad improves blood flow to the feet, addressing coolness due to diabetic neuropathy and poor circulation, while minimizing risks like burns in a client with reduced sensation.
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A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
- A. Obtain a prostate-specific antigen blood level test.
- B. Take vitamin supplements.
- C. Increase physical activity.
- D. Consume a high protein diet.
Correct Answer: C
Rationale: Increasing physical activity helps maintain a healthy weight and improves pelvic blood flow, reducing BPH risk factors, unlike PSA testing, supplements, or high-protein diets, which lack direct preventive benefits.
An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
- A. Clear, dark amber-colored urine.
- B. Improved level of consciousness.
- C. Prothrombin time within normal limits.
- D. Decreased abdominal girth.
Correct Answer: D
Rationale: Decreased abdominal girth reflects reduced ascites, confirming the effectiveness of low sodium diet and albumin infusions in managing fluid retention in hepatic failure.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Avoiding high-fat foods like whole milk and ice cream prevents exacerbation of cholecystitis, demonstrating effective understanding of dietary restrictions.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome?
- A. Husky voice and complaints of hoarseness.
- B. Warm, soft, moist, salmon-colored skin.
- C. Visible swelling of the neck, with no pain.
- D. Central-type obesity, with thin extremities.
Correct Answer: D
Rationale: Central-type obesity with thin extremities is a hallmark of Cushing's syndrome due to cortisol-induced fat redistribution and muscle wasting, making it a key finding to document.