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A postpartum client recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. What action should the nurse encourage the client to avoid?
- A. Brushing her teeth
- B. Taking acetylsalicylic acid (aspirin)
- C. Walking long distances and climbing stairs
- D. All activities because bruising injuries can occur
Correct Answer: B
Rationale: Aspirin is an antiplatelet medication and can interact with the anticoagulant medication and increase the clotting time beyond therapeutic ranges, so avoiding aspirin is a priority. The client does not need to avoid brushing her teeth, but she should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.
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The nurse determines that the client with gastroesophageal reflux disease (GERD) needs further teaching regarding diet if which statement is made?
- A. I need to avoid coffee, tea, and chocolate.
- B. I should eat four to six small meals a day.
- C. It is important that I drink extra fluids during meals.
- D. I need to avoid snacking for 2 to 3 hours before bedtime.
Correct Answer: C
Rationale: Gastroesophageal reflux disease (GERD) is the backflow of gastric and duodenal contents into the esophagus. Fluids must be taken between meals rather than with meals to prevent the overdistention that leads to reflux. Coffee, tea, cola, and chocolate are eliminated from the diet because they decrease lower esophageal sphincter pressure and can potentiate reflux. Four to six smaller meals per day will help to prevent gastric overdistention. One of the primary factors in GERD is an incompetent lower esophageal sphincter. Adequate time needs to pass after snacking and before bedtime to decrease the risk for the reflux of gastric contents.
The nurse is caring for a client who is a survivor of a disaster event. The client begins to display behaviors not demonstrated before. Which manifestations should indicate to the nurse that the client may be experiencing post-traumatic stress disorder (PTSD)? Select all that apply.
- A. Irritability and sleep disturbances
- B. Flashbacks or recollections of the disaster
- C. Regression to an earlier developmental stage
- D. A feeling of estrangement or detachment from others
- E. Consistent discussion and rationalizing as to why the disaster occurred
- F. Repression or the inability to remember an important aspect associated with the disaster
Correct Answer: A,B,D,F
Rationale: PTSD involves recurrent flashbacks, irritability, sleep disturbances, estrangement, and repression of trauma-related memories. Regression and rationalizing the event's cause are not typical PTSD symptoms. These manifestations indicate a sustained maladaptive response to the traumatic event, often with avoidance of trauma-related stimuli and psychological distress.
A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse should most importantly plan teaching strategies that are designed to do what?
- A. Promote membership in support groups.
- B. Encourage the client to become a more active person.
- C. Identify irritants in the home that interfere with breathing.
- D. Improve oxygenation and minimize carbon dioxide retention.
Correct Answer: D
Rationale: Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal.
The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?
- A. We'll check our child's blood pressure every day.
- B. We'll test our child's urine for albumin every week.
- C. It'll be so good to have our child back in tap-dancing classes next week.
- D. We'll be sure that our child eats a lot of vegetables and does not add extra salt to food.
Correct Answer: C
Rationale: Tap dancing classes 1 week after discharge would be unrealistic and involve a too rapid increase in activity. Glomerulonephritis results in destruction, inflammation, and sclerosis of the glomeruli of the kidneys. After discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Taking daily blood pressure, testing urine weekly for albumin, and restricting extra sodium are appropriate home care measures.
The nurse is caring for a pregnant client at 24 weeks. The client voids before the nurse measures the fundal height. Which finding by the nurse would be expected in assessment of this client?
- A. a fundal height of 22 to 26 cm
- B. a fundal height of 27 to 30 cm
- C. a fundal height of 29 to 33 cm
- D. a fundal height of 31 to 34 cm
Correct Answer: A
Rationale: At 24 weeks, fundal height typically measures 22-26 cm, corresponding to gestational age in centimeters.