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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Ask the client to describe her feelings about the loss of the affected limb.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Restrict visitors to family members until the client is able to wear a prosthesis.
- D. Suggest that family members bring clothing for the client from home.
- E. Instruct the client to ignore phantom pain sensations.
- F. Apply heat to the stump.
- G. Limit physical therapy.
Correct Answer: A,B,D
Rationale: Expressing feelings aids coping, peer support helps adjustment, and familiar clothing boosts morale; phantom pain should be addressed, not ignored.
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A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions?
- A. Monitor blood glucose while taking this medication
- B. Expect muscle pain while taking this medication.
- C. Take the medication with breakfast.
- D. Chew the medication before swallowing.
- E. Take it on an empty stomach.
- F. Expect weight gain as a side effect.
- G. Avoid all carbohydrates while on this.
Correct Answer: A
Rationale: Metformin requires glucose monitoring to assess efficacy and prevent hypoglycemia; muscle pain isn't typical, it's taken with food to reduce GI upset, and it's not chewed.
A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?
- A. Place on airborne precautions.
- B. Avoid direct contact.
- C. Isolate for 24 hr. after lesions appear.
- D. Administer a broad-spectrum antibiotic.
Correct Answer: B
Rationale: Avoiding direct contact prevents the spread of tinea corporis, a fungal infection. Airborne precautions and antibiotics are inappropriate, and isolation isn't required beyond contact precautions.
A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Peripheral edema
- C. Decreased respirations
- D. Absent bowel sounds
Correct Answer: D
Rationale: Absent bowel sounds indicate paralytic ileus, a common finding in peritonitis due to inflammation. Polyuria, edema, and decreased respirations are not typical.
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client consumed citrus juice 3 days before the test.
- B. The client takes ibuprofen for headaches.
- C. The client had a hemorrhoidectomy 1 year ago.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Fecal occult blood tests detect hidden blood in stool, often for colorectal cancer screening, but false positives can skew results. Ibuprofen, an NSAID, irritates the gastric mucosa, causing microbleeding that may appear in stool, unrelated to colonic sources. Citrus juice doesn't affect heme detection vitamin C may cause false negatives, not positives, and 3 days prior minimizes impact. A hemorrhoidectomy 1 year ago is healed, unlikely to bleed now unless complications persist, which isn't suggested. Breast cancer history doesn't influence gastrointestinal bleeding unless metastatic, an unlikely scenario here. Ibuprofen's known GI side effects align with testing guidelines (e.g., avoiding NSAIDs pre-test), making it the most likely false-positive trigger, requiring the nurse to clarify timing and adjust interpretation.
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Turn the client every 2 hr to prevent pressure ulcers.
- B. Place a mirror in the client's room for reality orientation.
- C. Offer the client written instructions for performing oral hygiene.
- D. Ask the client open-ended questions to encourage conversation.
Correct Answer: A
Rationale: Late-stage Alzheimer's impairs mobility and cognition, increasing pressure ulcer risk from prolonged immobility. Turning the client every 2 hours redistributes pressure, maintains skin integrity, and aligns with evidence-based prevention (e.g., Braden Scale interventions). A mirror for reality orientation is ineffective late-stage patients lack recognition, and it may cause distress. Written instructions are useless due to severe cognitive decline; simplified, hands-on guidance is better for tasks like oral hygiene. Open-ended questions frustrate clients unable to process or respond, whereas yes/no prompts suit their capacity. Regular repositioning addresses a physical priority, prevents costly complications like infections or surgery, and supports dignity in care, making it the essential action for this vulnerable population.