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A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. By reassuring the client that feeling anger about the diagnosis of colorectal cancer is a normal part of the grieving process, the nurse acknowledges the client's emotions and validates their experience. This can help the client feel understood and supported, fostering a therapeutic relationship. Discussing risk factors (A) may not address the client's current emotional needs. Teaching future management (B) may be premature as the client is currently expressing anger. Providing written information on loss and grief phases (C) may not directly address the client's anger. Therefore, the best immediate action is to validate the client's emotions and offer reassurance (D).
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For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn’s disease.
- A. Fever
- B. Steatorrhea
- C. Anemia
- D. Weight loss
- E. Diarrhea
Correct Answer: A, B, C, D
Rationale: To determine which assessment findings are consistent with ulcerative colitis, diverticulitis, or Crohn's disease, we need to analyze the characteristics of each condition.
1. Fever : This finding can be seen in all three conditions, but it is more commonly associated with Crohn's disease due to the inflammatory nature of the disease.
2. Steatorrhea (B): This is a common symptom of Crohn's disease due to malabsorption issues, making it a key indicator for this condition.
3. Anemia (C): Anemia is a common complication of inflammatory bowel diseases like ulcerative colitis and Crohn's disease, often related to chronic inflammation and blood loss.
4. Weight loss (D): This is a common feature of all three conditions due to malabsorption, decreased appetite, and chronic inflammation.
Therefore, the correct answer is A, B, C, D as these findings are consistent with all three conditions. Diarrhea (E
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should turn on the ceiling fan to block out unwanted noise.
- B. I will limit my daily nap to 45 minutes.
- C. I will drink a cup of green tea at bedtime to help me sleep.
- D. I should get out of bed if I cannot fall asleep within an hour of lying down.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Limiting naps to 45 minutes can help improve nighttime sleep in individuals with insomnia by reducing excessive daytime sleepiness and ensuring better sleep quality at night. Longer naps can disrupt the body's natural sleep-wake cycle and make it harder to fall asleep at night. This statement shows an understanding of the importance of sleep hygiene practices for managing insomnia.
Summary:
A: Turning on the ceiling fan may help create white noise, but it does not address the underlying issue of improving sleep quality.
C: Drinking green tea before bedtime can actually worsen insomnia due to its caffeine content.
D: Getting out of bed if unable to sleep within an hour can disrupt the sleep routine and make it harder to fall asleep.
Therefore, the correct choice is B as it directly addresses the management of insomnia by improving sleep habits.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This is correct because the proper fit of sequential compression sleeves is essential for effective use. Ensuring that two fingers can fit under the sleeves ensures that they are not too tight, which could impede circulation.
Explanation for why the other choices are incorrect:
A: Assisting the client into a prone position is not necessary for applying sequential compression sleeves.
B: Placing a sleeve over the top of each leg with the opening at the knee is incorrect as the opening should be at the ankle.
D: Setting the ankle pressure at 65 mm Hg is incorrect as pressure settings should be determined based on the individual's needs and the healthcare provider's orders.
A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body.
- C. The nurse should use the same needle to draw up and inject the client.
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A. Using a filter needle to withdraw the medication from a glass ampule helps prevent glass particles from contaminating the medication. Breaking the neck of the ampule toward the body (choice B) can lead to injury. Using the same needle to draw up and inject the client (choice C) increases the risk of contamination. Disposing of the ampule in the trash can (choice D) without following proper disposal protocols can be hazardous.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place a container for soiled linens inside the client's room. This intervention is important to prevent the spread of infection. Placing a container for soiled linens inside the client's room ensures that contaminated linens are contained and not mixed with other linens, reducing the risk of transmitting the infection to others.
Rationale for why other choices are incorrect:
A: Wearing an N95 mask is not necessary unless the client has airborne precautions, such as tuberculosis.
C: Placing the client in a negative airflow room is typically reserved for clients with airborne infections to prevent the spread of droplet nuclei in the air.
D: Removing the mask after exiting the client's room is incorrect as the mask should be removed before exiting to prevent contamination outside the room.
In summary, choice B is correct as it directly addresses infection control measures related to soiled linens, while the other choices are not relevant to isolation precautions or are incorrect based on standard