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A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?
- A. Use the cane on the stronger side
- B. Advance the cane and the weaker leg at the same time
- C. Use the cane on the weaker side
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: A
Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.
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A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?
- A. Hyperactivity
- B. Hypervigilance
- C. Restlessness
- D. Avoidance of social situations
Correct Answer: B
Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.
What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?
- A. Fluid restrictions are not needed for all clients with chronic kidney disease.
- B. You may need to limit fluid intake to prevent fluid overload.
- C. Fluid restrictions are based on your lab results and daily weights.
- D. Restricting fluids is only necessary during dialysis.
Correct Answer: B
Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.
How should a healthcare professional manage a patient with congestive heart failure?
- A. Administer diuretics and monitor fluid balance
- B. Provide a high-sodium diet and restrict fluids
- C. Administer oxygen and provide pain relief
- D. Provide bronchodilators and encourage mobility
Correct Answer: A
Rationale: Correct answer: The most appropriate management for a patient with congestive heart failure is to administer diuretics to help remove excess fluid and monitor fluid balance. Diuretics help reduce the workload on the heart and alleviate symptoms of fluid overload. Choice B is incorrect because patients with congestive heart failure are usually advised to limit sodium intake and carefully monitor fluid intake. Choice C is incorrect because although oxygen therapy may be necessary in certain cases, it is not the primary management for congestive heart failure. Pain relief is not a primary intervention for this condition. Choice D is incorrect because bronchodilators are not the first-line treatment for congestive heart failure. Encouraging mobility is important, but administering diuretics and monitoring fluid balance take precedence in managing this condition.
A client with a tracheostomy is exhibiting signs of respiratory distress. What is the nurse's immediate priority?
- A. Increase the oxygen flow rate
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Administer a bronchodilator
Correct Answer: B
Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.
A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?
- A. The client exhales deeply before inhaling
- B. The client attempts to elevate the cylinder by inhaling deeply
- C. The client inhales quickly through the spirometer
- D. The client inhales several short breaths
Correct Answer: B
Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.