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A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
- A. Encourage continued maintenance of the walking routine.
- B. Advise less weight-bearing to prevent joint destruction.
- C. Recommend walking indoors for improved stability and safety.
- D. Suggest a calcium supplement along with continued walking.
Correct Answer: A
Rationale: Encouraging the client to continue their walking routine supports their desire to stay active and promotes muscle strength, flexibility, and overall well-being, which are beneficial for managing osteoarthritis.
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A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
- A. Elevate the head of the bed.
- B. Initiate a bowel prep protocol for surgery.
- C. Educate the patient on increasing dietary fiber.
- D. Maintain the patient's NPO status.
Correct Answer: D
Rationale: Maintaining NPO status rests the bowel, promoting healing during acute diverticulitis.
The nurse is assessing a patient's understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?
- A. The patient exclusively consumes lactose-free dairy products.
- B. The patient meticulously cleans and peels all fresh fruits and vegetables.
- C. The patient enjoys fat-free yogurt as an occasional snack.
- D. The patient has eliminated grains from their diet.
Correct Answer: C
Rationale: Consuming fat-free yogurt aligns with the DASH diet's emphasis on low-fat dairy, supporting blood pressure control.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?
- A. Cold and dry skin.
- B. Facial puffiness and periorbital edema.
- C. Hematocrit of 30% (0.30 volume fraction).
- D. Further decline in the level of consciousness.
Correct Answer: D
Rationale: A further decline in consciousness indicates worsening hypothyroidism or myxedema coma, requiring urgent intervention.