Nokea
A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching?
- A. Use water-based lubricant during intercourse to reduce discomfort.
- B. Take estrogen supplements without consulting a provider.
- C. Limit calcium intake to reduce bloating.
- D. Avoid all physical activity to conserve energy.
Correct Answer: A
Rationale: The correct answer is A: Use water-based lubricant during intercourse to reduce discomfort. This instruction is important for managing menopausal symptoms like vaginal dryness and discomfort during intercourse. Water-based lubricants can help alleviate these symptoms. Option B is incorrect as taking estrogen supplements without consulting a provider can have risks and side effects. Option C is incorrect because limiting calcium intake is not recommended during menopause, as calcium is important for bone health. Option D is incorrect as avoiding physical activity can worsen menopausal symptoms and impact overall health.
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A nurse is assessing a client who has Cushings syndrome. Which of the following findings should the nurse expect?
- A. Osteoporosis
- B. Hypertension
- C. Weight loss
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. In Cushing's syndrome, excess cortisol weakens bones, leading to osteoporosis. B: Hypertension is common in Cushing's due to cortisol's effects on blood vessels. C: Weight gain, not loss, is typically seen in Cushing's due to cortisol-induced fat redistribution. D: Hyperglycemia, not hypoglycemia, is common due to cortisol's role in glucose metabolism. E, F, G are irrelevant. In summary, osteoporosis is expected due to cortisol's impact on bone health, while the other options are not typical findings in Cushing's syndrome.
A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?
- A. A client receiving chemotherapy for early-stage breast cancer.
- B. A client whose medications to manage Parkinsons disease are no longer effective.
- C. A client recovering from a total knee replacement.
- D. A client with seasonal allergies needing symptom relief.
Correct Answer: B
Rationale: The correct answer is B because the client with Parkinson's disease whose medications are no longer effective may benefit from the specialized care and symptom management provided by palliative care. Palliative care focuses on improving quality of life for individuals with serious illnesses by addressing physical, emotional, and spiritual needs. Referral is appropriate when symptoms are not adequately controlled. Choices A, C, and D do not require palliative care as they involve routine treatments or procedures that do not necessarily indicate the need for specialized palliative services.
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
- A. The client reports ringing in the ears.
- B. The client is becoming flushed.
- C. The client reports increased thirst.
- D. The client has a decreased urine output.
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
- A. Use only powder-free latex gloves.
- B. Place monitoring cords and tubes in a stockinette.
- C. Avoid using iodine-based antiseptics.
- D. Administer prophylactic antihistamines.
Correct Answer: B
Rationale: The correct answer is B: Place monitoring cords and tubes in a stockinette. This is important for the client with a latex allergy because stockinettes provide a barrier between the latex-containing materials and the client's skin, reducing the risk of allergic reactions. Using powder-free latex gloves (choice A) is a good practice, but it is not directly addressing the risk of exposure to latex for the client. Avoiding iodine-based antiseptics (choice C) is not necessary unless the client has a specific allergy to iodine. Administering prophylactic antihistamines (choice D) is not a standard practice for latex allergies and may not prevent an allergic reaction.
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?
- A. The stool will be firm and well-formed.
- B. The stool will have a high volume of liquid.
- C. The stool will be similar to normal bowel movements.
- D. The stool will be hard and difficult to pass.
Correct Answer: B
Rationale: The correct answer is B: The stool will have a high volume of liquid. Following a colectomy with an ileostomy, the client will have fecal output from the small intestine, resulting in a high volume of liquid stool. This is because the large intestine, responsible for absorbing water and forming solid stool, is bypassed with an ileostomy. Choice A is incorrect because the stool will not be firm and well-formed. Choice C is incorrect because the stool will not be similar to normal bowel movements due to the absence of the large intestine. Choice D is incorrect as the stool will not be hard and difficult to pass.