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A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
- A. Instruct the client to sit on a rubber ring when seated in a chair.
- B. Raise the head of the client's bed to a 90° angle.
- C. Place pillows between the client's knees when in a side-lying position.
- D. Use moisturizing lotion while massaging the client's bony prominences.
Correct Answer: C
Rationale: The correct answer is C: Place pillows between the client's knees when in a side-lying position. Placing pillows between the knees helps maintain proper alignment of the hips and spine, preventing the development of pressure ulcers and improving comfort for the client. Choice A is incorrect as sitting on a rubber ring does not directly address the client's hemiplegia. Choice B is incorrect because raising the head of the bed to a 90° angle may not be suitable for a client with hemiplegia due to potential issues with positioning and pressure distribution. Choice D is incorrect as using moisturizing lotion while massaging bony prominences is not a specific intervention for hemiplegia care.
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A nurse is providing discharge teaching to a client who had a bilateral orchiectomy. The nurse should instruct the client to expect which of the following symptoms?
- A. Hypoglycemia
- B. Increased libido
- C. Hot flashes
- D. Increased muscle mass
Correct Answer: C
Rationale: The correct answer is C: Hot flashes. After a bilateral orchiectomy (removal of both testicles), there is a sudden decrease in testosterone levels, leading to hormonal imbalances. This can result in hot flashes, which are commonly experienced by men undergoing androgen deprivation therapy. Hypoglycemia (A) is not typically associated with orchiectomy. Increased libido (B) and increased muscle mass (D) are actually expected to decrease due to the decrease in testosterone levels post-orchiectomy.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the best option because it ensures effective communication between the nurse and the client. By having a professional interpreter present, the nurse can accurately gather information, provide instructions, and address any concerns the client may have. Asking a family member to be present (A) may not guarantee accurate communication. Familiarizing with sign language (C) may not be sufficient for complex medical discussions. Using a board with pictures (D) may not be effective for detailed conversations.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 minutes after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample.
- B. Check the client's vital signs.
- C. Stop the infusion.
- D. Administer oxygen to the client.
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client's symptoms suggest a transfusion reaction, which could be life-threatening. Stopping the infusion is the priority to prevent further harm. Checking vital signs can wait, as immediate action is needed. Collecting a urine sample is not urgent in this situation. Administering oxygen is not indicated unless the client shows signs of respiratory distress, which is not mentioned in the scenario.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.'
- B. You should avoid intercourse to prevent injury to your vagina.'
- C. Women your age experience thickening of the vaginal tissue.'
- D. Your symptoms are likely due to decreasing estrogen levels.'
Correct Answer: D
Rationale: The correct answer is D: "Your symptoms are likely due to decreasing estrogen levels." This response is correct because vaginal dryness and itching are common symptoms of vaginal atrophy, which is often caused by decreased estrogen levels in older adult women. The nurse's acknowledgment and explanation of this physiological change can help the client understand the root cause of her symptoms and guide further discussion on appropriate treatment options, such as hormone therapy or vaginal moisturizers.
Choice A is incorrect because it dismisses the client's discomfort without addressing the underlying cause. Choice B is incorrect as it provides potentially harmful advice without addressing the issue. Choice C is incorrect as it inaccurately describes the condition of vaginal tissue in older women.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk with you before you leave.'
- B. I can contact the occupational therapist to schedule a home visit.'
- C. Contact your pharmacy to inquire about a different medication.'
- D. You should ask your provider to prescribe a cheaper medication.'
Correct Answer: A
Rationale: The correct answer is A: "I can arrange for a social worker to talk with you before you leave." This option is the most appropriate as it addresses the client's financial constraints by offering assistance in accessing support services. A social worker can help the client explore options for medication assistance programs, financial aid, or community resources. Option B is incorrect as it does not directly address the client's medication affordability issue. Option C suggests switching medications without considering the client's specific needs. Option D places the burden on the client to navigate the healthcare system for cost-effective solutions. Option A is the best choice as it prioritizes addressing the client's financial barriers through appropriate referral and support.