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A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase the amount of fresh fruits and vegetables I consume.'
- B. I will need to take my clothes to the dry cleaners to sterilize them.'
- C. I will be sure to wear gloves and wash my hands when I change my cat's litter box.'
- D. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Using alcohol to wipe up areas soiled with body fluids helps to disinfect the surfaces, reducing the risk of infection spread.
2. Immediately disposing of the trash containing body fluids prevents further exposure to infectious materials.
3. This statement demonstrates understanding of infection control measures crucial for someone with AIDS.
Incorrect Choices:
A: Increasing fresh fruits and vegetables is a healthy choice but not directly related to preventing infection spread in the context of AIDS.
B: Taking clothes to the dry cleaners for sterilization is unnecessary and does not address infection control.
C: Wearing gloves and washing hands when changing a cat's litter box is a good hygiene practice but not specific to preventing transmission of HIV.
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A nurse is providing teaching to a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: Avoiding crowds helps reduce the risk of exposure to infections, crucial for neutropenic clients.
C: Taking temperature daily allows early detection of fever, a sign of infection.
B: Weekly toothbrush washing does not directly impact infection risk.
D: Fresh fruits and vegetables are good for health but not specific to neutropenia management.
A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?
- A. Projectile vomiting
- B. Decorticate posturing
- C. Restlessness
- D. Papilledema
Correct Answer: C
Rationale: The correct answer is C: Restlessness. In early stages of increased ICP, the brain tries to compensate by increasing blood flow to maintain perfusion, leading to restlessness. Projectile vomiting (A) is a late sign due to pressure on the vomiting center. Decorticate posturing (B) and papilledema (D) are late signs of increased ICP.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Intrinsic factor
- B. Uric acid
- C. Chloride level
- D. Creatinine kinase
Correct Answer: B
Rationale: The correct answer is B: Uric acid. In acute gout, there is an accumulation of uric acid crystals in the joints, leading to inflammation and pain. As a result, the uric acid levels in the blood increase. Monitoring uric acid levels helps in diagnosing and managing gout.
Explanation for other choices:
A: Intrinsic factor - Intrinsic factor is related to vitamin B12 absorption, not gout.
C: Chloride level - Chloride level is not directly impacted by acute gout.
D: Creatinine kinase - Creatinine kinase is an enzyme related to muscle breakdown, not specifically affected by gout.
A nurse is caring for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowler’s position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. After a lumbar laminectomy, it is essential to prevent twisting or bending at the waist to avoid damaging the surgical site. Log rolling with a turning sheet maintains proper alignment of the spine. Encouraging independent ambulation (A) may put strain on the surgical area. Positioning in a high Fowler's position (C) may increase pressure on the surgical site. Applying a heating pad (D) can lead to increased inflammation and potential burns.
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema?
- A. Excessive somnolence
- B. Epistaxis
- C. Pink
- D. frothy sputum
- E. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Pink frothy sputum. This finding indicates pulmonary edema, which is characterized by fluid accumulation in the lungs. The pink color indicates the presence of blood in the sputum, a common sign of pulmonary edema. Excessive somnolence (A) is more indicative of respiratory depression or hypoxia, while epistaxis (B) is associated with hypertension or nasal trauma. Tachypnea (E) can be a sign of respiratory distress but does not specifically indicate pulmonary edema.