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A nurse is caring for a client who is constipated. What intervention is most appropriate?
- A. Administer a laxative to relieve discomfort
- B. Encourage the client to increase dietary fiber intake
- C. Encourage the client to rest until symptoms resolve
- D. Administer a stool softener as prescribed
Correct Answer: B
Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.
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The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?
- A. Paradoxical excitement
- B. Headache
- C. Slowing of reflexes
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.
When providing discharge teaching to a client with diabetes, what is the most important instruction?
- A. Check blood sugar levels once daily
- B. Administer insulin as prescribed before meals
- C. Take medication only when feeling unwell
- D. Eat carbohydrate-rich meals to stabilize blood sugar
Correct Answer: B
Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?
- A. Hypertension.
- B. Tachycardia.
- C. Cold extremities.
- D. Diaphoresis.
Correct Answer: C
Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.
A client is learning about preventing hip dislocation before total hip arthroplasty. Which instruction should be included?
- A. Avoid bending the hip more than 90 degrees
- B. Avoid lying on the unaffected side
- C. Avoid crossing the legs at the knees
- D. Avoid keeping the legs in a neutral position
Correct Answer: C
Rationale: The correct instruction to prevent hip dislocation after total hip arthroplasty is to avoid crossing the legs at the knees. This position can put stress on the hip joint and increase the risk of dislocation. Choices A, B, and D are incorrect. Bending the hip more than 90 degrees, lying on the unaffected side, or keeping the legs in a neutral position are not directly related to preventing hip dislocation in this context.
What are the key interventions for managing pneumonia?
- A. Administer antibiotics and monitor oxygen levels
- B. Administer bronchodilators and encourage deep breathing
- C. Provide fluids and monitor for dehydration
- D. Administer oxygen and provide bed rest
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.