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A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A - Excessive laxative use can lead to constipation by causing dependency on laxatives. B - Ignoring the urge to defecate can disrupt normal bowel habits. C - Inadequate fluid intake can result in hard stools and difficulty passing them. Choices D and E are incorrect because increased fiber in the diet and increased activity are actually recommended interventions to alleviate constipation.
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A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B because even though the client is unconscious, research has shown that individuals in such states may still have some level of awareness. Talking to the client can provide comfort, stimulate brain activity, and maintain a sense of connection. Choices A, C, and D are incorrect because they do not address the potential benefits of talking to the unconscious client. A deflects the question, C dismisses the partner's concern, and D praises the AP but does not explain the rationale behind talking to the client.
A nurse is reinforcing teaching about health promotion with a group of older adults. Which of the following health promotion measures should the nurse recommend? (Select all that apply.)
- A. Yearly blood pressure screening
- B. Use of lotions with a SPF of 15 or higher
- C. Immunization for influenza
- D. Annual visual acuity screening
- E. Reduce calcium intake.
Correct Answer: A,B,C,D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Yearly blood pressure screening is important for early detection and management of hypertension, a common health issue in older adults.
B: Using lotions with SPF of 15 or higher helps prevent skin damage and reduces the risk of skin cancer, a common concern in older adults.
C: Immunization for influenza is crucial in older adults to prevent serious complications from the flu due to their weakened immune systems.
D: Annual visual acuity screening is essential for detecting age-related vision changes and preventing accidents or falls.
Summary:
E: Reducing calcium intake is not a recommended health promotion measure for older adults, as adequate calcium is essential for bone health and preventing osteoporosis.
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next?
- A. Cleanse the meatus.
- B. Don sterile gloves.
- C. Cleanse the labia.
- D. Lubricate the catheter.
Correct Answer: B
Rationale: The correct next step is to don sterile gloves (choice B). This is essential to maintain aseptic technique and prevent infection during catheter insertion. Sterile gloves create a barrier between the nurse's hands and the client's urinary tract, reducing the risk of introducing pathogens. Cleansing the meatus (choice A) or labia (choice C) should come after donning sterile gloves to prevent contamination. Lubricating the catheter (choice D) should be done just before insertion to facilitate a smooth and comfortable procedure.
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea has been traditionally used in Chinese medicine to aid digestion by stimulating the production of digestive enzymes and reducing bloating and gas. This can be particularly beneficial for an older adult recovering from a bowel obstruction as it can help ease the digestive process and prevent further complications. Additionally, ginger has anti-inflammatory properties, which can also be helpful in reducing inflammation in the digestive tract.
Other choices are incorrect:
A: To regulate blood pressure - While ginger may have some benefits for heart health, its primary role in this scenario is to aid digestion, not regulate blood pressure.
C: To enhance the immune system - While ginger may have some immune-boosting properties, the primary reason for the client's request in this case is to aid digestion.
D: To reduce inflammation - While ginger does have anti-inflammatory properties, the main purpose of the client's request is to aid digestion rather than specifically targeting inflammation.
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.