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A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day.
- B. Avoid extremely hot or cold temperatures.
- C. Avoid getting a flu vaccination.
- D. Limit alcohol intake to one drink per day.
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is crucial for a client recovering from a sickle cell crisis as extreme temperatures can trigger or worsen a sickle cell crisis. Hot temperatures can lead to dehydration and increase the risk of vaso-occlusive events, while cold temperatures can cause vasoconstriction, leading to further sickling of red blood cells. Limiting fluids (A) is incorrect as hydration is important to prevent complications. Avoiding a flu vaccination (C) is also incorrect as it is recommended to protect against infections that can trigger a crisis. Limiting alcohol intake (D) is not directly related to sickle cell crisis recovery.
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A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Dry skin
- B. Alopecia
- C. Increased salivation
- D. Dolichocephaly
Correct Answer: A
Rationale: The correct answer is A: Dry skin. Malnutrition can lead to a deficiency in essential nutrients like vitamins and minerals, causing skin to become dry and flaky. This occurs due to a lack of proper hydration and nourishment. Alopecia (B) is more commonly associated with conditions like stress or hormonal imbalances. Increased salivation (C) is not typically linked to malnutrition but can be seen in conditions like GERD. Dolichocephaly (D) refers to an elongated shape of the head and is not directly related to malnutrition. In summary, dry skin is a manifestation of malnutrition due to the lack of essential nutrients, while the other choices are more likely associated with different conditions or factors.
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom dark at night.
- B. Cover electrical outlets in the client's home with tape.
- C. Hang a monthly calendar in the client's bedroom.
- D. Place a large-face clock in the client's bedroom.
Correct Answer: D
Rationale: The correct answer is D: Place a large-face clock in the client's bedroom. This is important for clients with Alzheimer's disease as they may have difficulty understanding the concept of time. A large-face clock with clear numbers can help the client orient themselves and maintain a sense of time. Keeping the client's bedroom dark at night (A) may actually increase confusion and disorientation. Covering electrical outlets in the client's home with tape (B) is not relevant to caring for a client with Alzheimer's disease. Hanging a monthly calendar in the client's bedroom (C) may be overwhelming and confusing due to the client's cognitive difficulties.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 36.3° C (90.9° F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A. Capillary refill time of 6 seconds in the toe indicates poor circulation, which is a concerning finding post-surgery with an external fixator. Immediate intervention is needed to prevent complications like tissue ischemia. Choices B, C, and D do not require immediate intervention as they are within normal limits postoperatively. Blood in the drain is expected, the temperature is normal, and pain level 7 is manageable with appropriate pain management.
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.