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A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: The correct answer is C: Increase water intake and use bulk-forming laxatives. This is because increasing water intake helps soften stool, making it easier to pass, and bulk-forming laxatives add bulk to stool, aiding in bowel movements for individuals with IBS-C. Stimulant laxatives (A) can lead to dependency and worsen symptoms. Avoiding fiber-rich foods (B) can exacerbate constipation. Eating a low-carbohydrate diet (D) may not directly address the constipation associated with IBS-C.
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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? (Select all that apply.)
- A. Excessive somnolence
- B. Epistaxis
- C. Pink frothy sputum
- D. Tachypnea
- E. Urinary frequency
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Excessive somnolence (A) can indicate inadequate oxygenation due to pulmonary edema. Pink frothy sputum (C) is a classic sign of pulmonary edema, caused by fluid leaking into the lungs. Tachypnea (D) is the body's response to decreased oxygen levels in the blood, characteristic of pulmonary edema. Epistaxis (B) and urinary frequency (E) are not typically associated with pulmonary edema. In summary, the correct answers reflect respiratory distress and inadequate oxygenation, while the incorrect choices are unrelated symptoms.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?
- A. Encourage the client to eat independently with utensils.
- B. Provide finger food at mealtime.
- C. Feed the client only pureed foods.
- D. Offer the client fluids only between meals.
Correct Answer: B
Rationale: The correct answer is B: Provide finger food at mealtime. This option is appropriate for a client with dementia as it promotes independence and encourages self-feeding, which can help maintain their dignity and autonomy. Finger foods are easy to handle and reduce the risk of frustration or confusion that may arise from using utensils. Encouraging self-feeding also helps stimulate cognitive function and maintain motor skills.
A: Encouraging the client to eat independently with utensils may be challenging and frustrating for someone with dementia.
C: Feeding the client only pureed foods may not be necessary if the client is able to eat regular food safely.
D: Offering fluids only between meals may lead to dehydration, especially for clients who may forget to ask for fluids when needed.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice A) are indicative of left-sided heart failure. Pink frothy sputum (choice C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice D) is not typically associated with right-sided heart failure.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- 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: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Upper left quadrant
- D. Mid-epigastric area
Correct Answer: B
Rationale: The correct answer is B: Left lower quadrant. Diverticular disease commonly causes pain in the left lower quadrant due to inflammation or infection of the diverticula, small pouches that can develop in the colon wall. This area corresponds to the location of the descending and sigmoid colon, where most diverticula occur. Pain in the right lower quadrant (choice A) is more indicative of appendicitis. Upper left quadrant pain (choice C) is more likely related to conditions involving the spleen or stomach. Mid-epigastric pain (choice D) is typically associated with issues related to the stomach or pancreas.