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A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?
- A. Use confrontation to manage the client's behavior.
- B. Limit the number of choices for the client.
- C. Provide a stimulating environment for the client.
- D. Use written signs to assist the client with locating the bathroom.
Correct Answer: B,D
Rationale: Limiting choices reduces confusion, and signs aid navigation. Confrontation increases agitation, and overstimulation can overwhelm clients with Alzheimer's.
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A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?
- A. Assist the client with relaxation techniques.
- B. Discourage intake of carbonated beverages.
- C. Offer toileting opportunities every 1 to 2 hr.
- D. Determine the client's pattern for voiding.
Correct Answer: D
Rationale: Assessing the client's voiding pattern first provides baseline data to tailor the bladder training program, ensuring interventions like toileting schedules or dietary changes are effective.
A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. The client reports mild abdominal discomfort.
- B. The client's bowel sounds are hypoactive.
- C. The client's incision is red and warm to the touch.
- D. The client has passed flatus.
Correct Answer: C
Rationale: Redness and warmth at the incision suggest infection, requiring prompt reporting. Mild discomfort, hypoactive sounds, and flatus are expected post-resection.
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following actions should the nurse take?
- A. Monitor the client for neck swelling.
- B. Instruct the client to resume a high-iodine diet.
- C. Apply a heating pad to the surgical site.
- D. Encourage the client to speak loudly to test vocal cords.
Correct Answer: A
Rationale: Neck swelling post-thyroidectomy could indicate hematoma or edema, requiring monitoring. High-iodine diets, heating pads, and loud speaking aren't appropriate.
A nurse is reinforcing teaching with a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?
- A. Increase your intake of potassium-rich foods.
- B. Take the medication at bedtime.
- C. Monitor for leg cramps.
- D. Limit your fluid intake to 1 liter daily.
Correct Answer: C
Rationale: Hydrochlorothiazide can cause hypokalemia, leading to leg cramps, which should be monitored. Potassium intake may need adjustment, it's taken in the morning, and fluid limits aren't standard.
A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?
- A. You can safely take this medication if you become pregnant.
- B. You can skip a dose of this medication if you are nauseated.
- C. You should expect to have blood work every 6 months while taking this medication.
- D. You might experience swollen gums while taking this medication.
Correct Answer: D
Rationale: Phenytoin can cause gingival hyperplasia, leading to swollen gums, a common side effect clients should monitor. It's teratogenic, skipping doses risks seizures, and blood work frequency varies.